Thursday, July 21, 2016

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 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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