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.

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