Modifier 54, 55, 56 - Surgical Care Only / Postoperative Management Only / Preoperative Management Only
Defines when Premera recognizes CPT services billed with modifier 54, 55, or 56 on professional claims and how reimbursement is adjusted; applies to Premera Blue Cross, Premera BCBS of Alaska, LifeWise plans and Premera HMO lines of business.
Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P electronic claim forms.
Inserted the phrase 'or other qualified healthcare professional' as a potential provider of services and added a second bullet under Modifier 54.
Added clarification that the documentation in the patient's medical record should document the portion of the global procedure rendered by each provider.
When Split Global Surgical Services Are Recognized
Coverage rules for split global surgical services
When a global surgical service is divided between providers from different practices, the Plan will recognize modifiers and adjust reimbursement as follows:
Reimbursement adjustments
- Modifier 54 — Surgical care only: reimbursement will be 70% of the provider's applicable Fee Schedule allowed amount.
- Modifier 55 — Postoperative management only: reimbursement will be 20% of the provider's applicable Fee Schedule allowed amount.
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