Split Post-Op Care and the Global Surgery Package

Medicare reimbursement for surgical procedures is based on a package of care that includes preoperative, intraoperative and postoperative care. When the package of care is split among multiple physicians or other health care practitioners, claims must be submitted according to these instructions in order for each physician to be reimbursed appropriately.

Physicians Who Furnish the Entire Global Surgery Package
Physicians who perform a surgery and furnish all of the usual pre- and postoperative work for the global package will report the appropriate surgical code only.

  • Postoperative care is generally included in the reimbursement for the surgery and is not separately payable
  • When the global surgical fee is submitted, CPT modifiers 54 and 55 do not apply
  • Postoperative care (E/M services) may be reimbursed separately if the care is not related to the surgery. Refer to instructions for CPT modifier 24 in the Palmetto GBA Modifier Lookup in the Forms/Tools section of this web page.

Physicians in a Group Practice

  • When different physicians in a group practice participate in the care of the patient, the group must submit the claim for the entire global package if the physicians reassign benefits to the group
  • The physician who performs the surgery must submit the service as the performing physician. The group that employs the physician must be reflected on the claim as the billing provider.
  • When the global surgical fee is submitted, CPT modifiers 54 and 55 do not apply

Physicians Who Furnish Part of a Global Surgery Package: Split Post-Op Care 
When physicians provide only part of the care in the global surgery package, each physician involved in the surgical and postoperative care must identify the specific services he/she provides. Payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of post-operative care.

  • CPT Modifier 54
    • Surgeons who perform the surgery should submit the surgery with CPT modifier 54 (surgical care only)
    • Payment is based on the pre-operative AND intraoperative percentages of the surgery’s physician fee schedule amount as indicated in the Pre-Op and Intra-Op fields of the Medicare Physician Fee Schedule Database (MPFSDB)
    • If the surgeon also provides a portion of the follow-up care, he/she should submit a separate detail line with CPT modifier 55 as indicated below
  • CPT Modifier 55
    • When the surgeon AND/OR other physician(s) provide the follow-up care, they should submit the surgery code with CPT modifier 55 (postoperative management only)
    • Payment is calculated based on the post-operative percentage of the surgery’s physician fee schedule amount as indicated in the Post-Op fields of the MPFSDB
    • The date of service must be the surgery date
    • The number of postoperative days must be indicated in the days/units field (or in the documentation record for electronic claims or Item 19 of the CMS-1500 claim form)
    • The assume/relinquished postoperative date of care must be indicated in the appropriate documentation record for electronic claims or in Item 19 of the CMS-1500 claim form
    • Each provider will be reimbursed based on the proportionate percentage of care, not to exceed the sum of the MPFSDB global surgery days assigned for the specific surgery
    • The sum of the amount approved for the surgery and postoperative care usually will not exceed the amount that would have been paid if a single provider provided the pre-op/surgery and postoperative care

Example of Split Postoperative Care
Patient A has a cataract removed from her left eye on January 17, by Dr. X. The surgery took place in an ambulatory surgical center (ASC). Dr. X follows her postoperatively for the first 10 days, then transfers the remainder of her postoperative care to Dr. Y.

Surgeon: Dr. X

 Date of Service CPT Code / CPT Modifier Place of Service Days/Units
 Electronic Documentation Field
Or Item 19
 1/17  66984-54LT  24 1 Blank
 1/17  66984-55LT  24 10 Care relinquished to Dr. Y on 1/17

 Physician to whom care was transferred to: Dr. Y 

 Date of Service CPT Code / CPT Modifier Place of Service Days/Units Electronic Documentation Field
Or Item 19
 1/17  66984-55LT  24  80 Care assumed from Dr. X; 1/18 

Exceptions
Exceptions apply when postoperative care is provided in the hospital immediately following surgery or in the emergency room. Refer to CMS Medicare Claims Processing Manual Pub 100-04, Chapter 12, Section 40.2.

References:

  • Refer to the Medicare Physician Fee Schedule Database (MPFSDB). Services reflecting a percentage in the preoperative, intraoperative, and postoperative fields of the database are valid for CPT modifiers 54 and 55.
  • Additional guidance regarding CPT modifiers 54 and 55 is available in the Palmetto GBA Modifier Lookup tool in the Forms/Tools section of this Web page
  • Refer to the following for additional information regarding Global Surgery: CMS Medicare Claims Processing Manual (PDF, 1.4 MB) (Pub. 100-04), Chapter 12, Sections 40 through 40.5

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