CPT Modifier 55

Published 02/14/2023

Description
Postoperative management only.

Guidelines and 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
  • To prevent duplicate denials and confusion, a laterality modifier (i.e., HCPCS modifier RT or LT), when applicable, should also be submitted and is required for some procedure codes. If the surgery was performed bilaterally and is valid for CPT® modifier 50, submit the surgery procedure code with CPT® modifiers 55 and 50 on one detail line, in lieu of submitting CPT® modifier 55 with RT or LT on separate detail lines.
  • To view the fee schedule post-operative percentage that applies to the surgery, refer to that column of Medicare Physician Fee Schedule database (MPFSDB)
    • Access the database directly from the CMS website
    • Example: If the Post-op column reflects 10 percent, the “allowed” amount for services submitted with CPT® modifier 55 will be reduced to 10 percent of the fee schedule amount if the post-op care was provided for the entire global days period. If less than the full global days of care was provided, the amount will be further reduced based on the number of days of care provided.

References


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