Split Surgical Package Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

The Surgical Package consists of the preoperative, surgical, and postoperative services. A Split Surgical Package occurs when the postoperative care is rendered by a physician other than the physician performing the surgical service. For example, one physician performs the surgical service only and turns the postoperative management over to a separate physician (not within the Same Group Practice). 

For purposes of this policy, Same Group Physician and/or Other Health Care Professional includes all physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number (TIN). 

Policy Codes

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Reimbursement Guidelines

Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare considers the surgical care rendered by the Same Group Physician and/or Other Health Care Professional to include preoperative management. Accordingly, in Split Surgical Package situations, the preoperative and surgical care portions of the Surgical Package are combined by UnitedHealthcare in the reimbursement of surgical codes appended with modifier 54. Preoperative care is not reimbursed separately by submission of the surgical code appended with modifier 56. Postoperative care management may be reimbursed separately when a physician or other health care professional who is not within the

Same Group Practice as the operating physician provides the postoperative care as denoted by submission of the surgical code appended with modifier 55.

Split Surgical Package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount, and are reimbursable at the percentages indicated:

Modifier

Percentage

54

80%

55

20%

56

0%

TOTAL:

100%

More than one physician may furnish services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the post-operative, post- discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, resulting in a combined payment that is higher than the global allowed amount. The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier.

For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

  • Modifier “-54” does not apply to assistant at surgery services.
  • Modifier “-54” does not apply to an ASC’s facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

  • Use modifier “-55” with the CPT code for global periods of 10 or 90 days.
  • Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in beneficiary’s medical record.
  • The receiving physician must provide at least one service before billing for any part of the post-operative care.