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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