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.
Bilateral Surgery
Bilateral procedures performed; Reference OAC 5160-4-22 Surgical Services for physician claims and appendix A, Outpatient Hospital Modifiers, to OAC rule 5160-2-21 for institutional claims.
Bilateral surgeries are procedures performed on both sides of the body at the same operative session or on the same day (two ears, two feet, two eyes, etc.)
Guidelines for bilateral procedures are as follows:
** The surgical procedure should be billed on a single line with modifier 50 and one unit.
** Modifier 50 should not be used to report:
o Procedures that are bilateral by definition or their descriptions include the terminology as “bilateral” or “unilateral”.
o Diagnostic and radiology facility services. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied.
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 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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