Payment Guidelines for Modifiers -54, -55, and -56
Posted 07/27/11

Effective for charges incurred on or after January 1, 2012, HealthChoice, Department of Corrections, and the Department of Rehabilitation Services are implementing payment guidelines for the following modifiers established by the American Medical Association.

These modifier codes and guidelines are appropriate when services are billed by separate physicians:

Modifier -54 Surgical Care Only — When one physician performs a surgical procedure and another provides preoperative and/or postoperative care management, surgical services can be identified by adding modifier -54 to the usual procedure code. Charges for a physician performing the surgical procedure under modifier -54 will be paid at 80% of the fee schedule.

Modifier -55 Postoperative Management Only — When one physician performs the postoperative care management and another physician performs the surgical procedure, surgical services can be identified by adding modifier -55 to the usual procedure code. Charges for the physician providing the postoperative component under modifier -55 will be paid at 20% of the fee schedule.

Modifier -56 Preoperative Management Only — When one physician performs the preoperative care evaluation and another physician performs the surgical procedure, surgical services can be identified by adding modifier -56 to the usual procedure code. Charges for the physician providing the preoperative component under modifier -56 will receive no reimbursement.

While reimbursement cannot exceed 100% of the Allowed Charge for the global surgical procedure, the modifiers allow for payment to each provider performing a component of the global surgical procedure.

If you have questions about these guidelines, please contact the Provider Relations Division at 1-405-717-8790 or toll-free 1-800-543-6044. Send email inquiries to oseegibproviderrelations@sib.ok.gov. 

DOC Network Providers should direct questions to DOC Provider Relations at 1-405-717-8750, toll-free 1-866-573-8462, or email DOCProviderRelations@sib.ok.gov. 

DRS Network Provider should contact DRS Provider Relations at 1-405-717-8921, toll-free 1-888-835-6919. Send email inquiries to DRSProviderRelations@sib.ok.gov.