CurrentUnitedHealthcarePolicy 2026R0106A

CMS-1500 billing for split/global surgical package

Governance of reimbursement for services billed on the CMS-1500 form relating to global surgical packages and split surgical package situations for UnitedHealthcare Commercial and Individual Exchange plans; affects all physicians and other qualified health care professionals billing on CMS-1500.

Policy Summary

PayerUnitedHealthcare

PolicyCMS-1500 billing for split/global surgical package

Policy CodePolicy 2026R0106A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen splitting the surgical package, append modifier 54 for the surgeon (surgical portion) and modifier 55 for the physician assuming postoperative care; maintain a written transfer agreement and ensure the receiving physician provides at least one service before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

54=80%/55=20%/56=0%reimbursement percentage split for split surgical package modifiers

CMS-1500form/application scope

Commercial & Exchangeplan applicability

Same TINSame Group definition

Split Surgical Package Reimbursement Criteria

Policy Summary

PayerUnitedHealthcare

PolicyCMS-1500 billing for split/global surgical package

Policy CodePolicy 2026R0106A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Split Surgical Package reimbursement criteria

Reimbursement rules and documentation expectations for split surgical package scenarios.

When a Split Surgical Package occurs, UnitedHealthcare follows CMS methodology: preoperative management furnished by the Same Group Physician and/or Other Qualified Health Care Professional is considered part of the surgical package and is combined with the surgical care for reimbursement purposes.

Preoperative care reported by appending modifier 56 to the surgical code is not separately reimbursed (0%).

When the surgeon bills with modifier 54 (surgical care only), UnitedHealthcare reimburses 80% of the total global surgical allowable for that portion.

When a physician who is not in the Same Group furnishes postoperative management and bills with modifier 55 (postoperative care only), UnitedHealthcare reimburses 20% of the total global surgical allowable for that portion.

The combined reimbursement to all physicians for components of the global surgical package will not exceed 100% of the total global surgical allowable amount.

When more than one physician furnishes services included in the global surgical package, payment is split only where physicians agree to a transfer of care; the surgeon and the receiving physician must keep a written transfer agreement in the beneficiary's medical record.

Where a transfer of care does not occur, services by another physician may be paid separately or denied as not medically necessary depending on the circumstances.

Operational billing/documentation expectations: use the same CPT code and same date of service (date of surgery) when billing both the surgical-only and postoperative-only services; report the date care was relinquished or assumed; the receiving physician must provide at least one service before billing for post-operative care; modifier 54 does not apply to assistant-at-surgery services or ASC facility fees.

Modifiers, Codes, and Payment Limits

Global surgery modifiersModifier

Modifier 54	Surgical care only; surgeon relinquishes postoperative care
Modifier 55	Postoperative care only; billed by physician assuming post-op care
Modifier 56	Preoperative management only; not separately reimbursed when appended to surgical code

Global surgery modifiers (individual entries)Modifier

54	Percentage = 80%
55	Percentage = 20%
56	Percentage = 0%

Billing guidance for modifiersmixed

Modifier 54	Does not apply to assistant at surgery services or ASC facility fees; use with same CPT code and date of service when relinquishing postoperative care
Modifier 55	Use with same CPT code and date of service for postoperative management; applicable for global periods of 10 or 90 days; receiving physician must provide at least one service before billing; keep written transfer agreement in beneficiary medical record

Maximum combined payment — may not exceed 100% of total global surgical allowable amount.

Maximum combined paymentSplit Surgical Package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount.

Reimbursement distributionModifier 54 reimbursed at 80% of global allowable; Modifier 55 reimbursed at 20%; Modifier 56 reimbursed at 0%.

Basis for limitPolicy follows CMS methodology combining preoperative and surgical care for Same Group providers when applying the global allowance.

Billing and Documentation Actions

Billing Rule

Use modifiers and document written transfer when splitting global surgical package

When splitting the global surgical package the surgeon bills the surgical portion with modifier -54 and the physician assuming postoperative care bills with modifier -55. Modifier -56 (preoperative management only) is not separately reimbursed (0%); total combined payment will not exceed 100% of the global surgical allowable. The receiving physician must provide at least one postoperative service before billing and maintain a written transfer agreement in the beneficiary's medical record.

Surgeon: bill surgical care with modifier -54 (preoperative + surgical combined) — reimbursed 80%.
Receiving physician: bill postoperative care with modifier -55 — reimbursed 20%; use for global periods of 10 or 90 days.
Modifier -56: preoperative management only — not separately reimbursed (0%).
Same CPT code and date of service must be billed for both surgical-only and postoperative-only; report date of surgery as date of service and indicate date care was relinquished or assumed.
Physicians must keep copies of the written transfer agreement in the beneficiary's medical record.
Modifier -54 does not apply to assistant-at-surgery services or ASC facility fees.

Key Definitions

Same Group Physician/Other Qualified HCP

DefinitionAll physicians and/or Other Qualified Health Care Professionals of the same group reporting the same Federal Tax Identification number (TIN).

ScopeApplies to physicians and Other Qualified Health Care Professionals billing on the CMS-1500 or electronic equivalent under the same group TIN.

Policy implicationPreoperative management furnished by Same Group is considered part of the surgical package for reimbursement purposes.

Split Surgical Package

DefinitionA Split Surgical Package occurs when a component of the surgical package (preoperative, surgical, postoperative) is rendered by a physician other than the physician performing the surgical service.

Common scenarioOne physician performs the surgical service and turns postoperative management over to a separate physician not within the Same Group Practice.

Billing noteWhen care is transferred and modifiers are used, the receiving physician must provide at least one service before billing and maintain documentation of transfer per policy requirements.

Surgical Package

Components includedIncludes preoperative visits, services normally part of the procedure, management of complications, postoperative visits related to recovery, post-procedure pain management, most supplies (except exclusions), and miscellaneous routine services such as dressing changes and suture removal.

Examples of miscellaneous servicesRemoval of operative pack; removal of cutaneous sutures and staples; insertion, irrigation and removal of urinary catheters; routine peripheral IV lines; changes and removal of tracheostomy tubes.

Timing noteVisits after the decision for a procedure begin the day before the procedure for major procedures and the day of the procedure for others.