When it comes to surgical procedures, modifiers convey to the payer a detailed story of exactly what occurred during the operative session. And since surgical claims cannot be paid correctly if submitted incorrectly, it’s imperative to get the modifier story straight the first time. As such, this series of articles will detail exactly which modifier should be used in a variety of surgical cases.
Termination of Surgical Cases
Modifier –53, Discontinued Procedures
The patient began having heart problems and the cataract surgery could not be completed. In a situation such as this or because of other circumstances that threaten the well being of the patient, the physician may elect to terminate a surgical or diagnostic procedure. However, surgeon and facility fees are still payable with the appropriate documentation. The physician must report the circumstance by adding CPT modifier –53 to the CPT code for the discontinued procedure.
In terms of properly documenting the claim, the physician should include a concise statement that explains why it was medically necessary to discontinue the procedure, along with any other supporting documentation that the surgeon deems relevant. For electronic claims, this statement may be entered in the electronic documentation field or submitted via fax attachment. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form.
An operative note should also accompany the claim, detailing:
- How much of the surgery was completed and
- Reasons that the surgery was terminated.
Modifier –53 should not be used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
Services that are submitted with CPT modifier –53 without this documentation will be returned as unprocessable with remark code MA130. The service then must be corrected and resubmitted as a new claim.
Outpatient hospital and ambulatory surgery centers may not submit CPT modifier –53. Instead, CPT modifiers –73 and –74 should be used when reporting that a previously scheduled procedure or service has been partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia.
Comanagement of Surgical Cases
Modifiers –54, Surgical Care Only, and –55, Postoperative Management Only
Modifier –54 should be appended to the surgical CPT code when the surgeon performs only the surgery and does not expect to provide postoperative care.
Modifier –55 should be appended when a physician provides postoperative care. This modifier can also indicate that payment for the postoperative care is split between two or more physicians when the physicians agree on the transfer of postoperative care. The exception occurs 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. When a physician other than the surgeon provides the postoperative care, CMS reimburses the postoperative physician(s) directly for the portion of global surgery services furnished.
When the surgeon performs the surgery and provides partial postoperative care, the claim is as follows:
- Submit the surgery with CPT modifier –54 on one detail line.
- On a separate detail line, include the surgery date as the date of service, the surgery code with CPT modifier –55 and the number of postoperative days the patient was under the surgeon’s care (e.g., 14 days).
Note: The surgeon must keep a patient-signed transfer of care agreement in the patient’s chart.
Also note: Many commercial payers do not recognize comanagment and therefore do not recognize modifiers –54 or –55.
Case Study of Modifiers –54, –55
If, for example, a surgeon performs cataract surgery and two weeks of postoperative care, they will need to use both –54 and –55 as follows: CPT code 66984–54–eye modifier for the surgical component as well as CPT code 66984–55–eye modifier indicating the number of days that postoperative care was provided and the date that care was turned over to another physician.
The comanaging physician will then need to submit CPT code 66984–55 indicating the dates that they assumed and ended postoperative care.
Final note: The amount paid to two physicians is never more than the total global surgical fee provided by only one physician.
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About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series.