Modifier 55

Reimbursement Policy:
Modifier 55

Effective Date:
May 15, 2017

Purpose:
This policy provides guidelines for the reimbursement of eligible services appropriately appended with Modifier 55 by professional providers.

Definition:
Modifier 55 is used for postoperative management only when a qualified healthcare professional provides postoperative care and another performed the surgical procedure.

Scope:
All products are included, except products where Horizon is secondary to Medicare (i.e. Medigap). All Insured and ASO accounts are included.

Policy:
Horizon BCBSNJ will reimburse post-operative management services appropriately appended with Modifier 55 at 15% of the applicable Horizon BCBSNJ fee schedule amount.

Procedure:
Modifier 55, allow at 15% of the applicable Horizon BCBSNJ fee schedule. This percentage is based on the numerical average of CMS.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
  • Mandated or legislative required criteria will always supersede

Policy 103_v6.0_01202017