Definition
Modifier 55 is used when a provider performs only the post-operative phase of a procedure that has a global surgical package. The post-operative phase includes all visits and care from the day after surgery through the end of the global period (typically 0 or 90 days depending on code). Another provider performs the intraoperative and pre-operative phases. Modifier 55 indicates responsibility for post-op management only.
When to Use
- Primary care physician manages post-operative follow-up (55 modifier) after surgeon performs total knee replacement (27447-54 by orthopedic surgeon)
- Hospital-based hospitalist manages post-operative recovery after surgeon performs coronary artery bypass (33510-54); cardiologist bills 55 for outpatient post-op
- Group practice surgeon performs appendectomy (44960-54); different surgeon in same group manages post-operative visits (44960-55)
- Visiting surgeon does cataract surgery (66984-54); local ophthalmologist bills 66984-55 for post-operative exams
Documentation Requirements
Document post-operative visits and management in chart. Note date of surgery (by other provider) and global period end date. Document all post-op care provided: wound checks, suture removal, medication management, complication monitoring. Ensure only post-operative services are documented, not duplication of operative report or pre-operative evaluation. Each visit note should reference the global period dates.
Payer-Specific Rules
| Payer | Acceptance | Common Denials | Notes |
|---|---|---|---|
| Medicare | Accepted; split global fee | CO-20: Charge exceeds fee schedule | Pay only post-operative RVU portion (typically 10-20% of global). Require visit documentation. |
| Aetna | Accepted; requires coordination | CO-4: Service bundled | Pay post-op portion. Require other provider operative documentation and dates. |
| United Healthcare | Accepted with coordination | CO-56: Information incomplete | Pay post-op portion. Deny if surgeon already billed post-op care. |
| Cigna | Accepted with documentation | CO-20: Charge exceeds fee schedule | Will pay post-op portion. Require surgery date and operative surgeon documentation. |
| Humana | Accepted; standard post-op split | CO-55: Post-op care included | Pay post-operative RVU. Deny if overlap with surgeon post-op billing. |
Related Modifiers
Common Denials
| CARC Code | Reason | Primary Cause |
|---|---|---|
| CO-20 | Charge exceeds fee schedule | Billed full code charge; must bill reduced post-op-only fee. |
| CO-4 | Service bundled | Surgeon already billed complete global package; cannot also bill 55. |
| CO-55 | Post-op care included | Post-operative care already included in operative surgeon's billing. |
FAQ
What RVU percentage do I get for modifier 55?
Medicare typically 10-20% of global RVU (post-operative portion). Varies by code.
Can I bill multiple post-op visits during the global period?
No. Global period package includes all post-op visits. Individual visit codes not billed; 55 covers entire post-op phase.
What if a complication occurs during post-op phase?
Complication management is included in global package. Unless separate E/M for unrelated condition, no additional code.
Prevent These Denials
Altair's co-pilot validates post-operative modifier usage and documentation before submission.
Related Resources
- Modifier 54: Intraoperative care only
- Modifier 56: Pre-operative care only
- Medicare global surgery rules