CurrentWPS Health InsurancePolicy 1008

Split Surgical Care Reimbursement

Defines WPS reimbursement methodology for split/shared surgical services billed with modifiers 54, 55, and 56 for physicians and qualified health care professionals across commercial lines of business.

Policy Summary

PayerWPS Health Insurance

PolicySplit Surgical Care Reimbursement

Policy CodePolicy 1008

Change TypeNo material change

Effective DateJan 1, 2010

Next Review DateDec 1, 2026

Key ActionProviders must bill the same service code and use modifiers 54, 55, or 56; always submit the full billed amount for WPS to apply the reimbursement methodology.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70%surgical component (54)

20%postoperative component (55)

10%preoperative component (56)

100%combined maximum

Commerciallines of business

Split Surgical Care Reimbursement Criteria

Split Surgical Care reimbursement criteria

When split surgical care is provided, reimbursement will be allocated among providers using modifiers 54, 55, and 56 with the following percentage splits:

All providers must bill the same procedure code when splitting surgical care.

ALL of the following

Modifier 54 (surgical care only) reimbursed at 70% of Fee Schedule Allowance/Contracted Rate.
Modifier 55 (postoperative management only) reimbursed at 20% of Fee Schedule Allowance/Contracted Rate.
Modifier 56 (preoperative management only) reimbursed at 10% of Fee Schedule Allowance/Contracted Rate.

Policy Summary

PayerWPS Health Insurance

PolicySplit Surgical Care Reimbursement

Policy CodePolicy 1008

Change TypeNo material change

Effective DateJan 1, 2010

Next Review DateDec 1, 2026

Key ActionProviders must bill the same service code and use modifiers 54, 55, or 56; always submit the full billed amount for WPS to apply the reimbursement methodology.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifiers and Allowable Limits

Split surgical care modifiersModifier

54	Modifier indicating surgical care only
55	Modifier indicating postoperative management only
56	Modifier indicating preoperative management only

Maximum combined reimbursement

Maximum combined reimbursementSplit surgical care procedures will be reimbursed not to exceed 100% of the total global surgical allowable amount.

ApplicationApplies to services billed with modifiers 54, 55, and 56 when multiple physicians and/or QHPs provide components of care.

Billing requirementAll providers must bill the same service code; submit the full billed amount and WPS will apply the methodology.

Related adjustment ratesSee individual modifier adjustment rates: 54 = 70%, 55 = 20%, 56 = 10% of Fee Schedule Allowance/Contracted Rate.

Billing and Modifier Use

Billing Rule

Bill same service code and append modifier 54, 55, or 56; submit full global charge

Providers must bill the same procedure code when split surgical care is performed and indicate the component performed by adding modifier 54, 55, or 56 to that same service code. Submit the full billed amount; WPS will apply the reimbursement methodology.

Use modifier 54 to identify the surgical procedure component (surgical care only).
Use modifier 55 to identify the postoperative management component (postoperative management only).
Use modifier 56 to identify the preoperative management component (preoperative management only).
Always submit the full billed amount; WPS will adjudicate using the policy’s percentage adjustments.

Key Definitions

Fee Schedule Allowance (Allowed Amount)

DefinitionFee Schedule Allowance (allowed amount) - The maximum rate allowed for the health care services according to the fee schedule.

Use in reimbursementAdjustment rates for split surgical care modifiers (54/55/56) are applied to the Fee Schedule Allowance/Contracted Rate.

ScopeApplies to services reported on UB-04 and CMS-1500 forms per the policy's reimbursement methodology.

Qualified Health Care Professional (QHP)

TermQHP = Qualified Health Care Professional.

ContextQHPs may participate in split surgical care with physicians; modifiers 54/55/56 apply when multiple physicians and/or QHPs provide components of care.

Billing implicationWhen a QHP performs a component of care, the provider must bill the same procedure code and append the appropriate modifier to indicate the component provided.