Indicates that the billing provider performed only the preoperative evaluation and management for a surgery, while another provider performs the actual surgery (and usually post‑op care).
Purpose
To divide the global surgical package so that:
One provider may bill for pre‑op management (-56),
Another provider bills for surgical care only (-54),
Another may bill for post‑op management only (-55), when applicable.
How to Use
Append modifier -56 to the appropriate surgical CPT code (e.g., 27130‑56).
Used by the provider who:
Performed the pre‑op evaluation, risk assessment, optimization, and related management.
Does NOT perform the procedure itself or provide the postoperative care.
Common Payer Behavior / Caveats
Some payers consider -54 (surgical care only) to include the pre‑op component and will not separately reimburse -56, denying it as invalid or redundant.
For pre‑op clearance requested by the surgeon (e.g., PCP or cardiology), many payers expect:
Billing under an appropriate E/M service (office, consult, etc.), with pre‑op or clearance diagnoses,
Rather than billing the surgical CPT with modifier -56.
When NOT to Use Modifier 56
When the same surgeon performs the pre‑op, surgery, and post‑op care (bill the full global without -54/-55/-56).
When the encounter is a pre‑op clearance or consult and payer policy directs E/M coding instead of modifier -56 on the procedure.
When payer policy explicitly excludes/rejects -56.
Example Scenario
Surgeon (Dr. A) performs total knee arthroplasty and manages global post‑op care.
Another provider (Dr. B, different group) performs detailed pre‑op management only.
Theoretically: Dr. B could bill the TKA code with -56, paid at the pre‑op portion of the global.
In practice: Many payers require Dr. B to bill an E/M visit with pre‑op evaluation diagnoses instead, no modifier -56.
Related Modifiers (Global Package)
-54 - Surgical care only.
-55 - Postoperative management only.
-56 - Preoperative management only (this modifier).
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