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PAP253

CPT Modifiers 54, 55 and 56


Provider Administrative Policy

Section
Claims Submission
Policy Date
March 2009
Status/Date
Revised/November 2012
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

CPT Modifiers 54, 55 and 56

Use Modifiers 54, 55 and 56 to report the appropriate portion of surgical care rendered.

Modifier 54
Surgical care only - used when one physician has performed a surgical procedure and another provided postoperative management. Identify surgical services by adding modifier 54 to the procedure code.

Modifier 55
Postoperative management only - used when one physician performed the postoperative management and another physician performed the surgical procedure. Identify the postoperative component by adding modifier 55 to the procedure code.

Blue Cross of Idaho does not split the allowance for postoperative management if performed by more than one provider. Therefore, only the provider performing the majority of the postoperative management services should bill the modifier 55. If more than one provider submits a claim for the same services with a modifier 55, the claims are subject to audit and recoupment.

Blue Cross of Idaho will allow:

  • 90% of the maximum allowance or billed, whichever is less, for procedures submitted with modifier 54
  • 10% of the maximum allowance or billed, whichever is less, for procedures billed with modifier 55

Exceptions
The following 12 procedure codes are for the removal cataracts:

66830 66840 66850 66852 66920 66930
66940 66982 66983 66984 66985 66986

Blue Cross of Idaho will allow:
• 80% of the maximum allowance or billed, whichever is less, for modifier 54
• 20% of the maximum allowance or billed, whichever is less, for modifier 55 

Modifier 56
Preoperative management only - used when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Identify the preoperative component by adding the modifier 56 to the procedure code.

There is no pricing allowance for pre-operative management only services billed with a modifier 56.


Policy History

Date Action Reason
November 2012 Revised Language clarification on modifier 55

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