Modifier 56

Reimbursement Policy:
Modifier 56

Effective Date:
May 15, 2017

Purpose:
To provide guidelines for the application of modifier 56 when appropriately billed by professional providers.

Definition:
Modifier 56 is used for preoperative management only when a qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure.

Products:
All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap). All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon BCBSNJ will reimburse preoperative management services appropriately appended with modifier 56 at 10% of the applicable Horizon BCBSNJ fee schedule amount.

Procedure:
Modifier 56, allow at 10% of the applicable Horizon fee schedule. The above 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 104_v6.0_01202017