Indicates that the billing provider performed only the preoperative evaluation and management for a surgery, while another provider performs the actual surgery (and usually postāop care).
Purpose
To divide the global surgical package so that:
One provider may bill for preāop management (-56),
Another provider bills for surgical care only (-54),
Another may bill for postāop management only (-55), when applicable.
How to Use
Append modifier -56 to the appropriate surgical CPT code (e.g., 27130ā56).
Used by the provider who:
Performed the preāop 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 preāop component and will not separately reimburse -56, denying it as invalid or redundant.
For preāop clearance requested by the surgeon (e.g., PCP or cardiology), many payers expect:
Billing under an appropriate E/M service (office, consult, etc.), with preāop or clearance diagnoses,
Rather than billing the surgical CPT with modifier -56.
When NOT to Use Modifier 56
When the same surgeon performs the preāop, surgery, and postāop care (bill the full global without -54/-55/-56).
When the encounter is a preāop 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 postāop care.
Another provider (Dr. B, different group) performs detailed preāop management only.
Theoretically: Dr. B could bill the TKA code with -56, paid at the preāop portion of the global.
In practice: Many payers require Dr. B to bill an E/M visit with preāop evaluation diagnoses instead, no modifier -56.