Reimbursement policy update: Split-Care Surgical Modifiers

Category:  Medicaid


Policy update

Split-Care Surgical Modifiers

(Effective 05/01/20)

 

Currently, HealthKeepers, Inc. allows reimbursement of surgical codes for Anthem HealthKeepers Plus members appended with split-care modifiers unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by which modifier is appended to the procedure code:

 

• Modifier 54 (surgical care only): 70%

 

• Modifier 55 (postoperative management only): 20%

 

• Modifier 56 (preoperative management only): 10%

The global surgical package consists of preoperative services, surgical procedures and postoperative services.

 

Effective May 1, 2020, HealthKeepers, Inc. will no longer allow reimbursement of surgical codes appended with split-care modifiers unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. The global surgical package consists of preoperative services, surgical procedures and postoperative services.

 

For additional information regarding percentages and reimbursement criteria, view the Split-Care Surgical Modifiers reimbursement policy at https://mediproviders.anthem.com/va.