Modifier 56- Preoperative Management Only

Identifies preoperative management provided by a physician or qualified healthcare professional when another practitioner performs the surgery and associated postoperative care.

What Is Modifier 56?

Modifier 56 identifies preoperative management only when responsibility for a surgical global package is divided between different practitioners.

Under global surgery rules, payment for many procedures includes preoperative, intraoperative, and postoperative services. When these portions are furnished by different practitioners, modifiers may be used to identify each practitioner's responsibility.

The practitioner providing qualifying preoperative management reports the surgical procedure code with Modifier 56 when applicable.

Modifier 56 does not represent an ordinary preoperative office visit. It identifies the preoperative management portion of a surgical global package when that portion of care has been formally separated from the surgery and postoperative management.

When to Use Modifier 56

Preoperative Management Is Transferred: A practitioner is responsible for the qualifying preoperative portion of the surgical global package but does not perform the surgery.

Different Practitioner Performs Surgery: The operative portion of the procedure is performed by another physician or qualified healthcare professional.

Procedure Has an Applicable Global Package: The surgical procedure includes a preoperative component that can be separately allocated under payer rules.

Transfer of Care Is Documented: The medical record establishes how responsibility for the surgical care was divided.

Procedure Code Is Appropriate: The practitioner reports the applicable surgical procedure code with Modifier 56 according to payer requirements.

When NOT to Use Modifier 56

Routine Preoperative Evaluation: Do not automatically use Modifier 56 for every office visit or medical evaluation performed before surgery.

Practitioner Performs the Entire Global Package: Modifier 56 is unnecessary when the same practitioner provides the applicable preoperative, surgical, and postoperative care.

Decision for Surgery: Modifier 57 may be appropriate when an E/M service results in the initial decision to perform major surgery.

Unrelated Medical Evaluation: An unrelated service before surgery should be reported according to the coding rules applicable to that service rather than automatically using Modifier 56.

No Transfer or Division of Care: Modifier 56 should not be used simply because another practitioner is involved in the patient's treatment.

Billing Example

A patient requires surgery, but the preoperative management and surgical care are provided by different physicians.

One physician assumes responsibility for the qualifying preoperative management, while another physician performs the operation and manages the remaining applicable portions of care.

The practitioner responsible only for the preoperative management reports the appropriate surgical procedure code with Modifier 56.

Documentation should clearly establish the division of responsibility between the practitioners.

Documentation Requirements

Transfer of Care: Document the arrangement dividing responsibility for the patient's surgical care.

Preoperative Management: Identify the qualifying preoperative services furnished by the practitioner reporting Modifier 56.

Surgical Procedure: Clearly identify the procedure associated with the preoperative management.

Operating Practitioner: Document which physician or qualified healthcare professional is responsible for performing the surgery.

Dates of Service: Maintain accurate dates supporting when the preoperative management was furnished.

Global Surgery Status: Verify that the procedure and payer rules support separate reporting of the preoperative portion.

Billing and Claim Considerations

Modifier 56 is part of the split global surgical care modifier family along with Modifiers 54 and 55.

Modifier 54 identifies surgical care only, Modifier 55 identifies postoperative management only, and Modifier 56 identifies preoperative management only.

Medicare's global surgery guidance recognizes these modifiers when different practitioners furnish portions of the global surgical package. Payment is allocated according to the applicable preoperative, intraoperative, and postoperative percentages assigned to the procedure.

Payer policies may differ regarding Modifier 56. Providers should verify that the payer recognizes separate preoperative management reporting and confirm the procedure's global surgery status before submitting the claim.

Modifier 56 should not be confused with separately reportable E/M services. The modifier represents a portion of the global surgical package, not simply any encounter occurring before surgery.

Common Billing Mistakes

Using 56 for Every Preoperative Visit: A routine preoperative encounter does not automatically represent separately transferred preoperative management.

Confusing 56 With 57: Modifier 57 identifies an E/M service resulting in the decision for major surgery, while Modifier 56 identifies transferred preoperative management.

Reporting an E/M Code With 56: Modifier 56 generally identifies the preoperative portion of the global surgical package and is reported with the applicable surgical procedure code.

No Documented Division of Care: The record does not demonstrate that different practitioners were responsible for separate portions of the global package.

Using 56 When the Surgeon Provides All Care: There is no reason to split the global package when the same practitioner provides all applicable components.

Ignoring Payer Requirements: Not all payers process split global care identically.

Common Denial Reasons

Transfer of Care Not Supported: Documentation does not establish a valid division of surgical care.

Incorrect Modifier: The circumstances support Modifier 54, 55, 57, or another modifier instead.

Procedure Does Not Support Split Care: The underlying procedure or payer policy does not allow separate reporting of the preoperative component.

Insufficient Documentation: The medical record does not establish what preoperative management the reporting practitioner provided.

Incorrect Procedure Reporting: The procedure code or modifier combination does not correspond with the documented surgical care arrangement.

Payer Requirements Not Met: Required information for separately reporting preoperative management is missing.

Modifier 56 vs. Modifier 57

Modifier 56: Identifies the preoperative management portion of a divided global surgical package.

Modifier 57: Identifies an E/M service that results in the initial decision to perform major surgery.

The key difference is that Modifier 56 represents preoperative management within the global package, while Modifier 57 identifies the decision for surgery and is appended to the qualifying E/M service.

Modifier 56 vs. Modifiers 54 and 55

Modifier 56: Preoperative management only.

Modifier 54: Surgical care only.

Modifier 55: Postoperative management only.

Together, these modifiers identify the portions of a global surgical package when care is divided among different practitioners.

Frequently Asked Questions

Is Modifier 56 reported on the preoperative E/M code?
Generally, no. Modifier 56 identifies the preoperative management portion of the global surgical package and is reported with the applicable surgical procedure code when payer requirements permit.

Is Modifier 56 the same as Modifier 57?
No. Modifier 57 identifies a qualifying E/M service resulting in the decision for major surgery. Modifier 56 identifies preoperative management when responsibility for the global surgical package is divided.