Important Information on Modifier 54 and 55
WPS has identified a need to educate providers on the appropriate billing for surgical procedures when one physician performs the surgical care and another, who is not a member of the same group, performs the postoperative care. The Internet-Only Manual (IOM) provides guidance in Publication 100-4, Chapter 12, Section 40.
Claims should be submitted with modifier 54 when the surgeon only performs the surgical care and relinquishes all or part of the postoperative care to a physician who is not a member of the same group. The surgical procedure performed, with a 10 or 90-day postoperative period, should be appended with the modifier 54.
When billing modifier 55, please make sure that you are billing the date of surgery as the date of service. In addition, the date care was assumed and relinquished must be in Item 19 of the CMS-1500 form or the electronic equivalent. WPS needs the assumed and relinquished care information in order to properly reimburse for the correct number of post-operative days. Please coordinate your billing with the surgeon to ensure that the surgeon bills his/her claim with the 54 modifier.
Billing claims with correct modifier usage can be challenging. WPS Medicare offers many resources to help you submit your claims correctly the first time. Please review the resources on the following page for helpful education on modifiers:
http://www.wpsmedicare.com/mac/education/b_modifiers.shtml
Page Last Updated: Wednesday, 31-Dec-2008 10:48:57 CST
