Modifier 56: Preoperative (Pre-Op) Care Only

Definition

Modifier 56 is used when a provider performs only the pre-operative phase of a procedure that includes a global surgical package. The pre-operative phase includes all visits and evaluation before surgery to optimize patient for procedure. Another provider (surgeon) performs intraoperative and typically post-operative care. Modifier 56 indicates responsibility for pre-operative assessment, clearance, and optimization only.

When to Use

Primary care physician provides pre-operative clearance (56) for patient's orthopedic knee surgery (27447-54 by orthopedic surgeon)
Cardiologist performs cardiac stress test and medical optimization (56) for patient undergoing cardiac surgery (33510-54 by cardiothoracic surgeon)
Anesthesiologist conducts pre-operative evaluation and optimization (56) for patient's appendectomy (44960-54 by surgeon)
Renal specialist provides pre-operative renal clearance (56) for patient with renal disease undergoing elective surgery

Documentation Requirements

Document pre-operative evaluation: history and physical, risk assessment, optimization plan. Note target procedure and planned surgeon. Document clearance or conditional clearance for surgery. Include labs, imaging, consultations performed for pre-operative optimization. Do not include post-operative care documentation (that is surgeon's responsibility). Date of surgery should be noted. Do not duplicate surgeon's pre-operative note if surgeon also does pre-operative.

Payer-Specific Rules

Payer	Acceptance	Common Denials	Notes
Medicare	Accepted; split global fee	CO-20: Charge exceeds fee schedule	Pay only pre-operative RVU portion (typically 5-10% of global). Require clearance documentation.
Aetna	Accepted; coordinate with surgeon	CO-4: Service bundled	Will pay pre-op portion. Require pre-op date and operative surgeon coordination.
United Healthcare	Accepted with coordination	CO-56: Information incomplete	Pay pre-op portion. Deny if surgeon already billed pre-operative care.
Cigna	Accepted with documentation	CO-20: Charge exceeds fee schedule	Pay pre-op portion. Require surgery date and surgeon information.
Humana	Accepted; standard pre-op split	CO-56: Pre-op care included	Pay pre-operative RVU. Deny if overlap with surgeon pre-operative billing.

Related Modifiers

54 – Intraoperative care only. Billed by surgeon performing procedure.
55 – Post-operative care only. Billed by surgeon managing post-operative phase.
25 – Significant E/M. Use if separate E/M for unrelated condition at pre-op visit.

Common Denials

CARC Code	Reason	Primary Cause
CO-20	Charge exceeds fee schedule	Billed full code charge; must bill reduced pre-op portion.
CO-4	Service bundled	Surgeon already billed complete global package including pre-op.
CO-56	Pre-op care included	Pre-operative care already included in operative surgeon's global package.

FAQ

What RVU percentage do I get for modifier 56?

Medicare typically 5-10% of global RVU (pre-operative portion). Varies by code.

If I provide pre-op clearance and the surgeon also provides pre-op, who bills 56?

Only one provider should bill 56. If surgeon performs pre-operative, surgeon may include in global package (no 56). If independent provider does pre-op, that provider bills 56.

Can I bill modifier 56 on the surgery code or only on E/M codes?

Modifier 56 is appended to the surgery code (e.g., 27447-56), not separate E/M code. It indicates pre-operative phase of that surgery.

Prevent These Denials

Prevent pre-operative billing conflicts. Use a co-pilot to coordinate clearance documentation.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.

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