CurrentUnitedHealthcarePolicy 2023R9035A

Split surgical package billing on CMS 1500

Defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on CMS 1500 forms related to the surgical package, including split (54/55) billing and applicable provider groups; applies to network physicians and other qualified healthcare professionals serving Medicare Advantage enrollees.

Policy Summary

PayerUnitedHealthcare

PolicySplit surgical package billing on CMS 1500

Policy CodePolicy 2023R9035A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen transferring care during the global period, document a written transfer agreement in the beneficiary's medical record and ensure the receiving physician provides at least one service before billing post-operative care with modifier 55.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

80%modifier 54 typical %

20%modifier 55 typical %

100%combined cap

CMS 1500forms governed

Coverage Criteria for Split Surgical Package

Policy Summary

PayerUnitedHealthcare

PolicySplit surgical package billing on CMS 1500

Policy CodePolicy 2023R9035A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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The claim relates to a surgical service with a defined global surgical package (preoperative, surgical, and postoperative components).

See Surgical Package definition.

A Split Surgical Package situation exists: one or more components of the surgical package (preoperative, surgical, or postoperative) are rendered by a physician other than the physician performing the surgical service.

Split Surgical Package definition applies.

Preoperative care and the surgical care portion billed by the operating surgeon are combined and not reimbursed separately when billed with modifier 54.

Modifier 54 indicates the surgeon relinquishes post-operative care; preoperative care is included with surgical portion.

Postoperative care may be reimbursed separately when billed by a physician not in the Same Group Practice as the operating physician and the claim is submitted with modifier 55.

Receiving physician must provide at least one service before billing for any part of the post-operative care and must bill the same CPT code and date of surgery.

The same CPT procedure code and the same date of surgery must be reported on both the surgical-only (modifier 54) and postoperative-only (modifier 55) claims.

Date of service is the date the surgical procedure was furnished.

Modifier 54 and modifier 55 are not appropriate for assistant-at-surgery services or for ASC facility fees.

Do not use modifiers 54/55 for assistant-at-surgery or ASC facility fees.

When care is transferred during the global period, the surgeon and the physician furnishing post-operative care must keep a copy of the written transfer agreement in the beneficiary's medical record; the receiving physician must provide at least one service before billing.

Written transfer agreement and documentation required when transfer occurs.

Combined payments for split surgical package services will not exceed 100% of the total global surgical allowable; UnitedHealthcare typically allocates 80% to modifier 54 and 20% to modifier 55 (total = 100%).

Sum of approved amounts for all physicians may not exceed single-physician payment unless other policies allow higher payment.

Split global billing does not apply to procedures with a zero-day postoperative period.

Modifiers, Codes, and Payment Limits

Split global surgery modifiersModifierCovered

Modifier 54	Surgical care only — surgeon relinquishes post-op care; preoperative care combined with surgical portion and not reimbursed separately
Modifier 55	Post-operative management only — billed by physician not in same group as operating physician; receiving physician must provide at least one service

Combined payment cap

Combined payment capSum of payments for split surgical package may not exceed 100% of the total global surgical allowable.

Allocated percentages (typical)Modifier 54 = 80%; Modifier 55 = 20%; Modifier 56 = 0% (total 100%).

ScopeApplies to Split Surgical Package situations; split global-care billing does not apply to procedure codes with a zero-day postoperative period.

Provider Responsibilities and Billing Requirements

Documentation Required

Document written transfer agreement and meet service requirement before billing post-op care

When transferring care during the global period, the surgeon and the receiving physician must keep a copy of the written transfer agreement in the beneficiary's medical record; the receiving physician must also provide at least one service before billing for any portion of post‑operative care billed with modifier 55.

Maintain a copy of the written transfer agreement in the beneficiary's medical record.
Receiving physician must perform at least one service before billing post‑operative care (modifier 55).
Report the same CPT code and date of surgery on both surgical-only (modifier 54) and post-operative-only (modifier 55) claims and indicate the date care was relinquished or assumed.

Billing Rule

Monitor CMS and carrier updates — policy may change

UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with CMS or national coding guideline changes; providers are responsible for monitoring CMS and carrier updates and maintaining current billing practices.

Monitor CMS and local carrier websites for policy or regulatory changes.
Sign up for regular distributions from CMS and/or your local carrier to receive updates.
Ensure claims follow current CPT/CMS coding guidelines; UnitedHealthcare may publish a new version of the policy to reflect changes.

Key Definitions

Split Surgical Package

DefinitionA situation where the preoperative, surgical, or postoperative components of the surgical package are rendered by a physician other than the one performing the surgical service.

ExampleOne physician performs the surgical service only and transfers postoperative management to a separate physician not within the Same Group Practice.

Billing implicationWhen split occurs, use appropriate modifiers (e.g., 54 for surgical care only, 55 for postoperative management) to distinguish services.

Same Group Physician and/or Other Qualified Health Care Professional

DefinitionAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

Reimbursement relevanceServices furnished by members of the Same Group Practice are treated as rendered by the operating physician for purposes of combining preoperative and surgical care under modifier 54.

Claims guidancePostoperative care billed with modifier 55 is reimbursable separately only when provided by a physician or other qualified health care professional not within the Same Group Practice.

Surgical Package

DefinitionIncludes preoperative visits, services integral to the procedure, postoperative visits during the global period, post‑procedure pain management, supplies (except identified exclusions), and miscellaneous routine services related to recovery.

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

ComplicationsAdditional medical or surgical services required during the postoperative period because of complications (not requiring return to the OR) are included in the Surgical Package.