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Modifiers -54, -55 and -56 to be added to BCBSNC Corporate Medical Policy for Modifier Guidelines

Blue Cross and Blue Shield of North Carolina (BCBSNC) recognizes there are occasions when more than one eye care physician will provide services that typically are included in a global surgical package for cataract care. As an example, when an eye physician-surgeon performs a patient's preoperative care and the cataract surgical procedure but then transfers the member's care to another physician to provide the follow-up care; billing for components of the global surgical package may be required. To assist eye care providers with billing for their appropriate portion of a cataract surgical package, BCBSNC will be adding modifiers -54, -55 and -56 to our Corporate Medical Policy for Modifier Guidelines effective November 15, 2010. By adding these additional modifiers eye care physicians will be able to submit claims to BCBSNC for their level of care involvement in a patient's cataract surgery and request their appropriate portion of the surgical service's global allowance from BCBSNC

Use of the following modifiers may affect reimbursement for certain cataract surgical procedures when services are provided on or after November 15, 2010 and claims are coded with the appropriate modifier(s) appended to the principle surgical procedure code:

  • Modifier -54: Surgical care only, for use when one physician performs the cataract surgical procedure and another physician provides the preoperative care and/or postoperative management. Surgical services may be identified by adding modifier -54 to the surgical procedure code.
  • Modifier -55: Postoperative management only, for use when one physician performed the postoperative management and another physician performed the preoperative care and/or surgical procedure. The postoperative component may be identified by adding modifier -55 to the surgical procedure code.
  • Modifier -56: Preoperative management only, for use when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure and/or postoperative care. The preoperative component may be identified by adding modifier -56 to the surgical procedure code.

    (Typically, the same provider will perform both the preoperative care and the surgical procedure for cataract care. Subsequently, providers billing for both the preoperative and surgical components should report services by use of both modifiers -54 and -56).

BCBSNC publishes policy for modifiers that may affect claims payment for claims processed on our Power MHS claims processing system. This policy, along with other BCBSNC Medical Guidelines, Payment Guidelines and Evidence Based Guidelines are made available on our Web site at http://www.bcbsnc.com/services/medical-policy.

We appreciate your continued support of the BCBSNC networks and the care you provide to our members. If you have any questions about use of these modifiers, billing and reimbursement or would like to discuss this change in policy, please contact your regional BCBSNC Network Management representative for assistance

Network Management Contact Information

Charlotte (800) 754-8185 Hickory (877) 889-0002
Greensboro (888) 298-7567 Raleigh (800) 777-1643
Greenville (888) 291-1780 Wilmington (877) 889-0001