Orthopedic Billing Services / Case Study

Who owns the global days when the surgeon and the follow-up provider are not the same person?

An orthopedic group kept losing money on both ends of the 90-day global. Here is how a modifier 54 / 55 split-care rebuild made the surgical package add up to exactly one, not more and not less.

CMS GLOBAL SURGERY POLICY MOD 54 · 55 · 56 CY 2026 MEDICARE PFS

The short answer

The global surgical package is one payment split into three parts: pre-operative, intra-operative, and post-operative. When one physician operates and another handles follow-up, each bills the same surgical CPT on the same date of service and appends a modifier that claims only their slice. The operating surgeon uses modifier 54 (surgical care only). The provider managing recovery uses modifier 55 (postoperative management only). Do that, and neither side over-bills the global, neither side leaves money on the table, and the two claims reconcile to 100%.

The problem, in one picture

One fee, three slices, two providers

Medicare does not pay a separate fee for the surgery and the follow-up. It pays a single global amount and, in the National Physician Fee Schedule Relative Value File, publishes the percentage of that amount assigned to each phase of care. When care is transferred, the percentages are how the money is divided.

MOD 56Pre-op

MOD 54Intra-op (the operation)

MOD 55Post-op days

Illustrative proportions only. The exact pre / intra / post percentages are code-specific and published by CMS per procedure in the MPFS Relative Value File.

The group was not under-coding. It was double-owning. Two providers were each billing the full global for the same knee, and the payer was clawing one of them back six months later.

Field note, orthopedic split-care review

The three modifiers

54, 55, and the one people forget

Surgical care only

The operating physician performed the procedure but has transferred postoperative management to another provider. Payment covers the intra-operative (and, by default, pre-operative) portion of the global.

Bills: the operating surgeon

Postoperative management only

A different physician assumed care after surgery. Same CPT, same surgery date. The claim reports the postoperative slice of the global for the days that provider is responsible for.

Bills: the follow-up provider

Preoperative management only

Rare in practice, but real. When a separate provider handles only the pre-op work-up, modifier 56 carves out that first slice. Most Medicare payers fold pre-op into the surgeon's 54.

Bills: the pre-op provider (uncommon)

The global window

Where the hand-off lands on the calendar

Global periods carry an indicator on the fee schedule: 000, 010, 090, or MMM. Most orthopedic majors are 090. The split-care claims each report the dates that provider assumed care, so the postoperative days are never counted twice.

DAY 0Surgery

DAY 0-NSurgeon owns care

HAND-OFFCare transferred

DAY N-90Follow-up owns care

Modifier 54 window Modifier 55 window 090 global period

The rebuild

The transfer-of-care rule that makes both claims clean

CMS is explicit: a transfer of postoperative care must be documented. Both the surgeon and the receiving provider need a written agreement or transfer note showing the date responsibility changed hands. Without it, the 55 claim has no anchor and the payer denies.

Side by side

What each provider actually puts on the claim

Claim element	Operating surgeon (54)	Follow-up provider (55)
Surgical CPT	Same code	Same code
Modifier	54	55
Date of service	Date of the surgery	Date of the surgery (not the visit date)
Assumed / relinquished care dates	Required in documentation	Required in documentation
Number of post-op days assumed	Not applicable	Reported for the 55 portion
Transfer-of-care agreement	On file	On file
Bills the full global?	No	No

Split care is not a discount. It is arithmetic. Each modifier is a claim to a named fraction of one number, and the two fractions have to close.

ASP-RCM orthopedic billing team

What was breaking

The four failure modes we found first

Denial driver

Both billed the full global

Two claims for the same knee with no 54 or 55. The payer paid one, recouped the other, and the group never reconciled the take-back.

Denial driver

Mismatched surgery dates

The 55 claim used the office-visit date instead of the surgery date, so the two claims never linked and the postoperative portion denied.

Documentation gap

No transfer-of-care note

The follow-up provider assumed care informally. With nothing written and dated, the 55 line had no support on appeal.

Revenue leak

Surgeon absorbed the post-op for free

Some surgeons kept full care but a different site's provider saw the patient once, and nobody billed the 55, so the group under-collected the global.

Cite the source

The 2026 guidance this rebuild runs on

CMS global surgery policy defines the global surgical package and the pre-op / intra-op / post-op components paid under one fee (Medicare Claims Processing Manual, Chapter 12, Section 40).
Transfer of care rules require documented, dated agreements when postoperative management shifts providers, and specify the same-CPT, same-date claim structure (Manual Chapter 12, Section 40.2).
Modifiers 54, 55, and 56 carve the global into surgical-only, postoperative-only, and preoperative-only shares under the CPT modifier set recognized by CMS.
CY 2026 Medicare Physician Fee Schedule Final Rule sets the conversion factor and RVUs that determine the dollar value of each split slice for the year.
MPFS Relative Value File publishes the global period indicator (000 / 010 / 090 / MMM) and the pre / intra / post percentages per procedure that make the 54 and 55 shares add to the whole.

If your global periods are leaking on both ends, we find where.

ASP-RCM rebuilds orthopedic split-care billing so the operating surgeon and the follow-up provider each collect their exact share of the global, with the transfer-of-care documentation that survives an audit. Same surgery, two clean claims, 100% of the fee.

Talk to our orthopedic billing team → ASP-RCM Solutions · Orthopedic Billing Services