Modifier 54, 55, 58

Modifier 54

Surgical Care Only. When a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure code.

Instructions

Modifier 54 is used to explain that the surgeon performed the surgical procedure only and is relinquishing a part or all of the postoperative days to another physician.

Correct Use

Surgeon performs surgery only

Bill surgical date of service

Append modifier 54 to surgical code

Incorrect Use

Do not append modifier 54 if patient is under surgeon's care for the full 10 or 90 days of postoperative care

Do not append on ASC facility or assistant surgeons services

Claim Coding Example

An orthopedic surgeon performs an open tibial shaft fracture (27759) but relinquishes care to another physician for postoperative care.

Date     Treatment Description CPT/Modifier Units

3/9/16 Open tibial shaft fracture 27759 54 1

Modifier 55

Postoperative Management Only. When a physician or other qualified health care professional performs the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by appending a modifier 55 to the surgical procedure.

Instructions

Modifier 55 is used when the surgeon is either relinquishing all or part of the postoperative days to another physician.

Correct Use

• Surgeon performs part of postoperative care
• Submit claim with two lines using same date of service and procedure code;  append modifier 55 to line 2
• Include date span in Item 19 narrative of CMS-1500 claim form or electronic equivalent
• Submit claim with number of units as 1
• Physician rendering additional postoperative care
• Submit claim with surgery date and procedure code
• Include date span of assumed care in Item 19 narrative of CMS-1500 claim form or electronic equivalent
• Submit claim with number of units as 1

Incorrect Use

• Do not append modifier 55 when surgeon performs surgery only: no postoperative care
• See instructions on modifier 54
• Do not append modifier 55 if patient is under surgeon's care for full 10 or 90 days of postoperative care
• Do not append on ASC facility or assistant surgeons claims

Claim Coding Example

An orthopedic surgeon performs an open tibial shaft fracture (27759) and bills the surgery with modifier 54. The partial postoperative care (modifier 55) is provided by the surgeon for the initial 45 days (March 10 - April 23) and is then turned over to another physician for the remailing 45 days (April 24 - June 7).

Date Treatment Description CPT/Modifier Units

3/9/2016 Open tibial shaft fracture 27759 54 1

3/9/2016 Open tibial shaft fracture 27759 55 1

Comment field showing dates care provided

Date Treatment Description CPT/Modifier Units

3/9/2016 Open tibial shaft fracture 27759 55 1

Comment field showing dates assumed care

Modifier 58

Staged or Related Procedure or Service During Postoperative Period by Same Physician

Instructions

The same physician planned, at the time of the original surgery/procedure, a return trip to the operating or procedure room within the 10 or 90 day post op days

Correct Use

Treatment of problem requiring a return to the operating/procedure room

More extensive than original procedure

Unanticipated clinical condition

Therapy following a diagnostic, surgical procedure                               

Each case requires surgical documentation and evaluation Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in the same specialty, same group are to bill and are reimbursed as a single physician

Use modifier 78 for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

Incorrect Use

Not appropriate for E/M or assistant surgery services

Claim Coding Example

Patient has excision (11606) with a 10 day global and a complex repair closure (13101) planned 9 days after the surgical date, then append modifier 58 to the closure.

Treatment Description : Excision, malignant lesion trunk, arm, legs

CPT 13101 / Modifier 58

11606 : Repair closure