CPT Modifier 55

Description
Postoperative management only.

Guidelines/Instructions
Use this modifier to indicate that payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of postoperative care.

Exception: When both physicians are members of the same group, surgery must be submitted as a "global package" only and not separated into "surgical care only" and "postoperative management only" components.
  • Claim submission when postoperative management is split between two or more physicians:
    • Submit this modifier with the surgical procedure code and the date of the surgery as the date of service
    • For electronic claims, submit the assumed or relinquished date of the postoperative care in the documentation field and the number of postoperative days in the days/units field or documentation field
    • For paper claims, indicate the assumed or relinquished dates of the postoperative care in Item 19 of the CMS-1500 claim form and the number of post-operative days in the days/units field or Item 19
    • Each provider will be reimbursed based on the proportionate percentage of care
    • The combined number of postoperative care days provided by the two or more physicians cannot exceed the number of MPFSDB global days assigned to the surgical procedure code 
       
  • If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. CPT modifier 55 is not applicable.
  • When transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care submits the claim using subsequent hospital care codes for the inpatient hospital care and the surgical code with CPT modifier 55 for the post-discharge care

Reference

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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