Payment Policy

Policy Num:       PP.002.004
Policy Name:     Split Surgical Package
Policy ID:          [PP.002.004][Ac/FB/PP/ ][ 10-020 ]

Last Review:       Jun 21, 2024
Next Review:      Jun 20, 2025
 

Related Policies: None

Split Surgical Package

DESCRIPTION

This policy describes reimbursement for components of the global surgical package. The policy applies to professional services reported on a CMS1500 claim form (or its electronic equivalent).

The surgical package consists of preoperative, intraoperative (surgical), and postoperative components. The surgical package is usually performed by a single physician. A split surgical package occurs when the postoperative care is rendered by a physician other than the physician performing the surgical service.

Split surgical package services are reported using the surgical procedure code appended by the appropriate modifier based on the services performed:

Modifier 54: Surgical Care Only – When one 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 number.

Modifier 55: Postoperative Management Only – When one physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.

Modifier 56: Preoperative Management Only – When one physician or other qualified health care professional performed the preoperative care and evaluation and another performed the  surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.

EIMBURSEMENT INFORMATION

Triple-S considers the payment of surgical care rendered by a physician or other health care professional according to standard modifiers 54, 55 and 56.  In view of circumstances of multiple physicians may intervene in an episode of care, pre operative care and surgical procedure can be performed by different physicians.  Accordingly, in split surgical package situations, the preoperative and surgical care portions of the surgical package may be billed separatelly. Postoperative care management may be reimbursed separately when a physician or other qualified health care professional as the operating physician provides the postoperative care as denoted by submission of the surgical code appended with modifier 55.

Split surgical package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount and are reimbursable at the percentages indicated as follows:

If a claim line includes a procedure code with modifier 54, 55 or 56 appended and there is a claim line in history with the same procedure code for the same date of service from a different provider which does not include modifier 54, 55 or 56, the claim line with modifier appended will be denied.

When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services.

When more than one physician provides post operative care, the physicians have to agree on the transfer of care during the global period, and the following modifiers are used: 
   • “-54” for surgical care only; or 
   • “-55” for postoperative management only. 
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.”

BILLING/CODING INFORMATION:

Services that include only a component of a global surgical service should be submitted with the appropriate surgical code and amended with the appropriate modifier to indicate a split surgical package. Only those surgeries that include postoperative follow up days as part of the global surgical package are included in this payment policy.

HCPCS Coding/Modifiers:

RELATED MEDICAL COVERAGE GUIDELINES OR PAYMENT POLICIES:

None

EFERENCES:

1. American Medical Association, Current Procedural Terminology (CPT ®), Professional Edition

2. Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12, Section 40.1.D, “Physicians Furnishing Less Than the Full Global Package

3. Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12, Section 40.2, “Billing Requirements for Global Surgeries”

Policy History