Definition
Modifier 56 is used when a provider performs only the pre-operative phase of a procedure that includes a global surgical package. The pre-operative phase includes all visits and evaluation before surgery to optimize patient for procedure. Another provider (surgeon) performs intraoperative and typically post-operative care. Modifier 56 indicates responsibility for pre-operative assessment, clearance, and optimization only.
When to Use
- Primary care physician provides pre-operative clearance (56) for patient's orthopedic knee surgery (27447-54 by orthopedic surgeon)
- Cardiologist performs cardiac stress test and medical optimization (56) for patient undergoing cardiac surgery (33510-54 by cardiothoracic surgeon)
- Anesthesiologist conducts pre-operative evaluation and optimization (56) for patient's appendectomy (44960-54 by surgeon)
- Renal specialist provides pre-operative renal clearance (56) for patient with renal disease undergoing elective surgery
Documentation Requirements
Document pre-operative evaluation: history and physical, risk assessment, optimization plan. Note target procedure and planned surgeon. Document clearance or conditional clearance for surgery. Include labs, imaging, consultations performed for pre-operative optimization. Do not include post-operative care documentation (that is surgeon's responsibility). Date of surgery should be noted. Do not duplicate surgeon's pre-operative note if surgeon also does pre-operative.
Payer-Specific Rules
| Payer | Acceptance | Common Denials | Notes |
|---|---|---|---|
| Medicare | Accepted; split global fee | CO-20: Charge exceeds fee schedule | Pay only pre-operative RVU portion (typically 5-10% of global). Require clearance documentation. |
| Aetna | Accepted; coordinate with surgeon | CO-4: Service bundled | Will pay pre-op portion. Require pre-op date and operative surgeon coordination. |
| United Healthcare | Accepted with coordination | CO-56: Information incomplete | Pay pre-op portion. Deny if surgeon already billed pre-operative care. |
| Cigna | Accepted with documentation | CO-20: Charge exceeds fee schedule | Pay pre-op portion. Require surgery date and surgeon information. |
| Humana | Accepted; standard pre-op split | CO-56: Pre-op care included | Pay pre-operative RVU. Deny if overlap with surgeon pre-operative billing. |
Related Modifiers
Common Denials
| CARC Code | Reason | Primary Cause |
|---|---|---|
| CO-20 | Charge exceeds fee schedule | Billed full code charge; must bill reduced pre-op portion. |
| CO-4 | Service bundled | Surgeon already billed complete global package including pre-op. |
| CO-56 | Pre-op care included | Pre-operative care already included in operative surgeon's global package. |
FAQ
What RVU percentage do I get for modifier 56?
Medicare typically 5-10% of global RVU (pre-operative portion). Varies by code.
If I provide pre-op clearance and the surgeon also provides pre-op, who bills 56?
Only one provider should bill 56. If surgeon performs pre-operative, surgeon may include in global package (no 56). If independent provider does pre-op, that provider bills 56.
Can I bill modifier 56 on the surgery code or only on E/M codes?
Modifier 56 is appended to the surgery code (e.g., 27447-56), not separate E/M code. It indicates pre-operative phase of that surgery.
Prevent These Denials
Prevent pre-operative billing conflicts. Use a co-pilot to coordinate clearance documentation.
Related Resources
- Modifier 54: Intraoperative care only
- Modifier 55: Post-operative care only
- Medicare global surgery package rules