Friday, April 30, 2010

CPT modifier 62 - CO-Surgeons When to use and Guidelines

Surgical - 62 CO surgeon Modifier 

OVERVIEW

The Co-Surgeon and Team Surgeon Policy identifies which procedures are eligible for Co-Surgeon and Team Surgeon services as identified by the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS).

* A Co-Surgeon is identified by appending modifier 62 to the surgical code.

*  A Team Surgeon is identified by appending modifier 66 to the surgical code.

REIMBURSEMENT GUIDELINES

Co-Surgeon Services

Modifier 62 identifies a Co-Surgeon involved in the care of a patient at surgery. Each Co-Surgeon should submit the same Current Procedural Terminology (CPT) code with modifier 62.


For services included on the Co-Surgeon Eligible List, Oxford will reimburse Co-Surgeon services at 63% of the Allowable Amount to each surgeon subject to additional multiple procedure reductions if applicable (see Multiple Procedure Reduction section). The Allowable Amount is determined independently for each surgeon and is calculated from the Allowable Amount that would be given to that surgeon performing the surgery without a Co-Surgeon. The reimbursable percentage amount (63%) of allowable is based on the rate adopted by the Centers for Medicare and Medicaid Services (CMS), which allows 62.5% of allowable to each Co-Surgeon.

Exception: For New Jersey small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare Charges System (PHCS).


Co-Surgeon and Team Surgeon Eligible Lists

The Co-Surgeon and Team Surgeon Eligible List are developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with status code indicators "1" or "2" for "Co-Surgeons" are considered by Oxford to be eligible for Co-Surgeon services as indicated by the co-surgeon modifier 62.

Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purposes of this policy.

All codes in the NPFS with the status code indicators "1" or "2" for "Team Surgeons" are considered by Oxford to be eligible for Team Surgeon services as indicated by the team surgeon modifier 66.


Multiple Procedure Reductions

Multiple procedure reductions apply to Co-Surgeon and Team Surgeon claim submissions when one or more physicians are billing multiple CPT codes that are eligible for reductions. Refer to Oxford Multiple Procedures for application of multiple procedure reductions.

Assistant Surgeon and Co-Surgeon Services During the Same Encounter Oxford follows CMS guidelines and does not reimburse for Assistant Surgeon services, as indicated by modifiers 80, 81, 82, or AS, for procedures where reimbursement has been provided for eligible Co-Surgeon services, using the same surgical procedure code, during the same encounter.

If a Co-Surgeon acts as an Assistant Surgeon in the performance of additional procedure(s) during the same surgical session, the procedures are reimbursable services (if eligible per the Assistant Surgeon Eligible List) when indicated by separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.

Simultaneous Bilateral Services Simultaneous bilateral services are those procedures in which each surgeon performs the same procedure on opposite sides. Each surgeon should report the simultaneous bilateral procedures with modifiers 50 and 62. Assistant Surgeon services will not be reimbursed services in addition to the simultaneous bilateral submission as described in the Assistant Surgeon and Co-Surgeon Services During Same Encounter section in this policy.




62    Two surgeons: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure.Under such circumstances the separate services may be identified by adding the modifier 62 to the procedure number used by each surgeon for reporting his services.

Under some circumstances the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and /or the patient’s condition.

If two surgeons, usually with different skills, are required to perform a single surgical procedure, each surgeon bills for the procedure with modifier 62. Cosurgery also refers to single surgical procedures involving two surgeons performing the parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified by Centers for Medicare & Medicaid Services (CMS).

 The individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition and the additional physician is not acting as an assistant at surgery. If the two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62.

Instructions

Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (e.g., heart transplant or bilateral knee replacements). Documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Physician Fee Schedule Database (MPFSDB).

If the surgery is billed with a modifier 62 and the indicator is 1, the claim will suspend for manual review of any documentation submitted with the claim. If the surgery is billed with a modifier 62 and the indicator is 2, then the payment rule for two surgeons apply.

Correct Use

    Both surgeons must agree to append modifier 62 on their claim
        Reimbursement at 62.5% of MPFSDB
        Indicator in MPFSDB must be either 1 or 2
    Procedure code and diagnosis code should be same
    Billed amount might not be same

Incorrect Use

    Modifier 62 must be on both claims or one physician will be paid at 100% and other physician's claim will deny
    Both surgeons must use same CPT code

Claim Coding Example

Dr Smith and Dr Jones (both orthopedic surgeons) performed as co-surgeons an Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure). Co-surgery Indicator 2.

Dr Smith
Date CPT/Modifier Charge Units
02/20/2016 24006 62 $825 1

Dr Jones
Date CPT/Modifier Charge Units
02/20/2016 24006 62 $1025 1


Allowance based on 62.5% of the allowable for code 24006 for both surgeons. No documentation needed. So if the allowance is $752.04, then 62.5% of this amount is $470.03 for each surgeon.



Co-Surgery – Modifier 62


*Two surgeons work together as primary surgeons performing distinct parts of a procedure

*Both surgeons must agree to use modifier 62

*MPFSDB indicator must be 1 or 2

*Reimbursement based on 62.5% of allowance for each surgeon


Category           Indicator         Indicator Description


0 Co-surgeons not permitted for this procedure.

1 Co-surgeons could be paid; supporting documentation required to establish the medical necessity of two surgeons for the procedure

2 Co-surgeons permitted; no documentation required if two specialty requirements are met.



The Co-Surgeon and Team Surgeon Policy identifies which procedures are eligible for Co-Surgeon and Team Surgeon services as identified by the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS).

** A Co-Surgeon is identified by appending modifier 62 to the surgical code.
** A Team Surgeon is identified by appending modifier 66 to the surgical code.

Co-Surgeon Services

Modifier 62 identifies a Co-Surgeon involved in the care of a patient at surgery. Each Co-Surgeon should submit the same Current Procedural Terminology (CPT) code with modifier 62.

For services included on the Co-Surgeon Eligible List, Oxford will reimburse Co-Surgeon services at 63% of the Allowable Amount to each surgeon subject to additional multiple procedure reductions if applicable (see Multiple Procedure Reduction section below). The Allowable Amount is determined independently for each surgeon and is calculated from the Allowable Amount that would be given to that surgeon performing the surgery without a CoSurgeon. The reimbursable percentage amount (63%) of allowable is based on the rate adopted by the Centers for Medicare and Medicaid Services (CMS), which allows 62.5% of allowable to each Co-Surgeon. Exception: For New Jersey small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare Charges System (PHCS).

Co-Surgeon and Team Surgeon Eligible Lists

The Co-Surgeon Eligible List and Team Surgeon Eligible List are developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with status code indicators "1" or "2" for "Co-Surgeons" are considered by Oxford to be eligible for Co-Surgeon services as indicated by the co-surgeon modifier 62. Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purposes of this policy.

All codes in the NPFS with the status code indicators "1" or "2" for "Team Surgeons" are considered by Oxford to be eligible for Team Surgeon services as indicated by the team surgeon modifier 66.

Allowable Amount: The dollar amount eligible for reimbursement to the physician or health care professional on the claim. Contracted rate, reasonable charge, or billed charges are examples of Allowable Amounts. Assistant Surgeon: A physician or other health care professional who is assisting the physician performing a surgical procedure.

Co-Surgeons: Several physicians (usually with different specialties) working together as primary surgeons performing distinct part(s) of a procedure. Claims submitted by co-surgeons are identified with modifier 62. Team Surgeons: Three or more surgeons (with different or same specialties) working together during an operative session in the management of a specific surgical procedure. Claims submitted by Team Surgeons are identified with modifier 66.

• If there are two surgeons (identified by appending modifier 62 to the procedure) or a team of surgeons (identified by appending modifier 66 to the procedure), an assistant at surgery will not be allowed.

Billing and Coding Guidelines


• When medical necessity exists for two surgeons, both must bill the same procedure code and date of service, and both must append modifier 62. The fee schedule amount is increased by 25% and reimbursement is split equally between the two surgeons.

• Assistant surgeons DO NOT append modifier 62; an assistant surgeon is not considered a  co-surgeon. (If the physician is serving as an assistant, he should append modifier 80 or82. The primary surgeon cannot bill as a co-surgeon when an assistant surgeon is billed.)

The following chart has common scenarios in billing modifier 62. Current claim being processed History claim previously processed

Claim action taken by Medicaid  Procedure code 21270 Modifier 62 billed Procedure code 21270 No modifier 62 billed Same or different attending provider Medicaid will deny the claim billed with modifier 62. The surgical procedure has been previously paid as a single surgeon.

 Procedure code 21270 No modifier 62 billed Procedure code 21270 Modifier 62 billed Same date of service Same or different attending provider Medicaid will pay the current claim and will recoup the previously paid claim. The procedure code on the current claim is billed as a primary surgeon.

 Procedure code 21270 Modifier 62 billed Procedure code 21270 Modifier 80 (or 82) billed Same date of service Different attending provider Medicaid will pay the current claim and recoup the assistant in history. Medicaid will not allow an assistant surgeon if co-surgeons performed the surgery.  Procedure code 21270 Modifier 80 (or 82) billed Procedure code 21270 Modifier 62 billed Same date of service Different attending provider Medicaid will deny the current claim. Medicaid does not allow an assistant surgeon if co-surgeons perform the surgery.

Coding Guidelines Contact the automated Voice Inquiry System to determine if the procedure code in question can be billed with modifier 62.

Claims for Co-Surgeons and Team Surgeons

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery.

The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:

• If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62” (Two surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, such as, heart transplant or bilateral knee replacements. Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool.

NOTE: Some procedures require modifier “-62” and will be returned without payment if it is not used by both surgeons.

• If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Field 25 of the MFSDB identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”

• If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services. With regard to payment, for co-surgeons (modifier 62), the fee schedule amount related to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier 66) is paid for on a “by report” basis.



Claims for Co-Surgeons and Team Surgeons

A.General

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery.

B.Billing Instructions

The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons:

*If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62.” Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (See §40.8.C.5.);

*If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66.” Field 25 of the MFSDB identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”

*If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services. (See §40.6 for multiple surgery payment rules.)

For co-surgeons (modifier 62), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier 66) is paid for on a “By Report” basis.

C.Claims Processing System Requirements

Carriers must be able to:

1.Identify a surgical procedure performed by two surgeons or a team of surgeons by the presence on the claim form or electronic submission of the “-62” or “-66” modifier;

2.Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;

3.Access Field 24 or 25, as appropriate, of the MFSDB. These fields provide guidance on whether two or team surgeons are generally required for the surgical procedure;

4.If the surgery is billed with a “-62” or “-66” modifier and Field 24 or 25 contains an indicator of “0,” payment adjustment rules for two or team surgeons do not apply:

*Carriers pay the first bill submitted, and base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply;

*Carriers deny bills received subsequently from other physicians and use the appropriate MSN message in §§40.8.D. As these are medical necessity denials, the instructions in the Program Integrity Manual regarding denial of unassigned claims for medical necessity are applied;

5.If the surgery is billed with a “-62” modifier and Field 24 contains an indicator of “1,” suspend the claim for manual review of any documentation submitted with the claim. If the documentation supports the need for co-surgeons, base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);

6.If the surgery is billed with a “-62” modifier and Field 24 contains an indicator of “2,” payment rules for two surgeons apply. Carriers base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);

7.If the surgery is billed with a “-66” modifier and Field 25 contains an indicator of “1,” carriers suspend the claim for manual review. If carriers determine that team surgeons were medically necessary, each physician is paid on a “by report” basis;

8.If the surgery is billed with a “-66” modifier and Field 25 contains an indicator of “2,” carriers pay “by report”;

NOTE: A Medicare fee may have been established for some surgical procedures that are billed with the “-66” modifier. In these cases, all physicians on the team must agree on the percentage of the Medicare payment amount each is to receive. If carriers receive a bill with a “-66” modifier after carriers have paid one surgeon the full Medicare payment amount (on a bill without the modifier), deny the subsequent claim.

9.Apply the rules global surgical packages to each of the physicians participating in a co- or team surgery; and

10.Retain the “-62” and “-66” modifiers in history for any co- or team surgeries.

D.Beneficiary Liability on Denied Claims for Assistant, Co- surgeon and Team Surgeons

MSN message 23.10 which states “Medicare does not pay for a surgical assistant for this kind of surgery,” was established for denial of claims for assistant surgeons. Where such payment is denied because the procedure is subject to the statutory restriction against payment for assistants-at-surgery. Carriers include the following statement in the MSN:

"You cannot be charged for this service.” (Unnumbered add-on message.)

Carriers use Group Code CO on the remittance advice to the physician to signify that the beneficiary may not be billed for the denied service and that the physician could be subject to penalties if a bill is issued to the beneficiary.

If Field 23 of the MFSDB contains an indicator of “0” or “1” (assistant-at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.

For those procedures with an indicator of “0,” the limitation on liability provisions described in Chapter 30 apply to assigned claims. Therefore, carriers include the appropriate limitation of liability language from Chapter 21. For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity.

Where payment may not be made for a co- or team surgeon, use the following MSN message (MSN message number 15.13):

Medicare does not pay for team surgeons for this procedure.

Where payment may not be made for a two surgeons, use the following MSN message (MSN message number 15.12):

Medicare does not pay for two surgeons for this procedure.

Also see limitation of liability remittance notice REF remark codes M25, M26, and M27. Use the following message on the remittance notice:
Multiple physicians/assistants are not covered in this case. (Reason code 54.)

40.9- Procedures Billed With Two or More Surgical Modifiers

Carriers may receive claims for surgical procedures with more than one surgical modifier. For example, since the global fee concept applies to all major surgeries, carriers may receive a claim for surgical care only (modifier “-54”) for a bilateral surgery (modifier “-50”). They may also receive a claim for multiple surgeries requiring the use of an assistant surgeon.

Following is a list of possible combinations of surgical modifiers. (NOTE:  Carriers must price all claims for surgical teams “by report.”)
*Bilateral surgery (“-50”) and multiple surgery (“-51”).
*Bilateral surgery (“-50”) and surgical care only (“-54”).

*Bilateral surgery (“-50”) and postoperative care only ("55”).
*Bilateral surgery (“-50”) and two surgeons (“-62”).
*Bilateral surgery (“-50”) and surgical team (“-66”).
*Bilateral surgery (“-50”) and assistant surgeon (“-80”).
*Bilateral surgery (“-50”), two surgeons (“-62”), and surgical care only (“-54”).
*Bilateral surgery (“-50”), team surgery (“-66”), and surgical care only (“-54”).
*Multiple surgery (“-51”) and surgical care only (“-54”).
*Multiple surgery (“-51”) and postoperative care only ("55”).
*Multiple surgery (“-51”) and two surgeons (“-62”).
*Multiple surgery (“-51”) and surgical team (“-66”).
*Multiple surgery (“-51”) and assistant surgeon (“-80”).
*Multiple surgery (“-51”), two surgeons (“-62”), and surgical care only (“-54”).
*Multiple surgery (“-51”), team surgery (“-66”), and surgical care only (“-54”).
*Two surgeons (“-62”) and surgical care only (“-54”).
*Two surgeons (“-62”) and postoperative care only (“55”).
*Surgical team (“-66”) and surgical care only (“-54”).
*Surgical team (“-66”) and postoperative care only (“55”).
Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier “-62”) or team surgeons (modifier “-66”) is appropriate. If carriers receive a bill for an assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.

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