In the complex world of revenue cycle management (RCM), accuracy in claim submission can be the difference between approval and denial. At Cair Health, our AI-powered platform ingests hundreds of thousands of payer policy PDFs to extract actionable insights, ensuring your claims are aligned with payer rules. To demonstrate the power of this approach, let’s take a closer look at an example reimbursement policy published by a national payer:
Highmark’s reimbursement policy for surgical modifiers 54, 55, and 56 (Bulletin Number: RP-005).
Highmark’s reimbursement policy outlines the appropriate usage of modifiers 54, 55, and 56 in surgical claims. These modifiers indicate how care responsibilities are split between providers during the global surgical period. This might seem like a niche topic, but hidden in this policy are critical reimbursement rules that could significantly impact the success of your claims.
Example Insights from the Policy
Modifier 54: Surgical Care Only
- Coding Rules: This modifier applies when a surgeon performs the operation but transfers postoperative management to another provider. The modifier is appended to the surgical procedure code.
- Reimbursement Rules:
- Commercial Plans: 70% of the approved allowance.
- Medicare Advantage (PA, WV, DE): Code-specific pre-op and intra-op percentages from the Medicare Physician Fee Schedule (MPFS).
- Medicare Advantage (NY): 70% of the approved allowance.
Modifier 55: Postoperative Management Only
- Coding Rules: This modifier applies when a provider exclusively handles postoperative care. The receiving provider must be licensed to manage all aspects of postoperative care, including diagnosing potential complications.
- Reimbursement Rules:
- Commercial Plans: 20% of the approved allowance.
- Medicare Advantage (PA, WV, DE): Code-specific post-op percentages multiplied by the percentage of the post-op period handled.
- Medicare Advantage (NY): 20% of the approved allowance.
Modifier 56: Preoperative Management Only
- Coding Rules: This modifier is used when a provider performs only preoperative care. The modifier is appended to the surgical procedure code.
- Reimbursement Rules:
- Commercial Plans: 10% of the approved allowance.
- Medicare Advantage: NY (10% of the approved allowance), but no reduction is applied in PA, WV, and DE.
Invalid Procedure Code Combinations:
- Modifiers 54, 55, and 56 do not apply to certain provider types (e.g., assistant surgeons, ambulatory surgery centers, inpatient hospitals).
- They are also invalid for obstetric care codes, which already have specific codes for shared care scenarios.
What This Means for Providers
Without proper knowledge of these nuances, providers risk claim denials or underpayment. For example, failing to append the correct modifier when transferring care can result in a denial for services rendered. Additionally, understanding the reimbursement breakdown for each modifier ensures that providers bill appropriately for their portion of care and can easily identify when remitted claims are underpaid.
How Cair Health Leverages Real-Time Policy Rules
Highmark’s policy is just one of the 150,000+ payer policy PDFs our platform processes. Using advanced AI, we:
- Extract and standardize guidelines like those in this policy.
- Apply these rules in real time to ensure accurate claim submissions.
- Help providers maximize their reimbursement by preventing errors tied to policy misinterpretation.
Highmark’s modifier policy may seem straightforward, but its nuances highlight why payer policies are such a critical data source for RCM automation. At Cair Health, we make these complexities manageable by leveraging AI to surface actionable insights hidden within dense policy documents. The result? Fewer claim denials, faster reimbursements, and peace of mind for providers.
