# CoSurgeon



## Henson65 (Jul 17, 2020)

Hi all,
I have two spine surgeons (same specialty) who are preforming surgeries together as co-surgeons. I received the first surgeons OP note and it lists the other physician as the co-surgeon however the body of the OP note refers to "we" in several different places. I received the second surgeons OP note and essentially it looks as though surgeon #2 pulled surgeon #1's OP note and made the change of listed surgeon#1 as the co-surgeon. Nothing is distinct or different between the two OP notes however both surgeons are arguing that they should be billed as co-surgeons. From my understanding of co-surgeons each surgeon needs to provide an OP note that notates distinct services provided and there really shouldn't be overlap between the two. My question is to be sure that this criteria is the same even though both surgeons are of the same specialty, that each needs to provide their own OP note that is distinct and different from the other surgeon notating what each surgeon did to act as the "primary" surgeon instead of both submitting the same OP note with "we" used throughout. Any guidance, tips, references would be extremely appreciated as I've been back and forth all week with these two surgeons who want me to just code/bill what they say.


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## SharonCollachi (Jul 17, 2020)

You are correct, otherwise it would more of an assistant at surgery.

BCBS of North Carolina Policy:   Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative session.  Services by surgeons of different specialties or subspecialties each performing distinct components of a procedure as primary surgeons will be allowed at 120% of the maximum allowance for the primary procedure. Multiple procedure guidelines may apply if additional procedures are performed. *Each surgeon should document his/her distinct operative work in a separate operative report.* Claims from both co-surgeons should report the same procedure code with modifier 62 appended. The total allowance for the operative session will be divided equally between the co-surgeons.  Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty. 

Medicare Policy Co-Surgery and Modifier 62:   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. 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, i.e., heart transplant. See more at link here.

Medicare Modifier 62 Fact Sheet:  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 and the additional physician is not acting as an assistant at surgery. If the two surgeons (each a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62.
*Guidance:  *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). When billing the surgical procedure with modifier 62, documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Physician Fee Schedule Database (MPFSDB) Indicator List:

Indicator of 1- supporting documentation is required to establish medical necessity of two surgeons for the procedure
Indicator of 2 - the payment rule for two surgeons apply

*Correct Use*
Both surgeons must agree to append modifier 62 on their claim
Reimbursement is made at 62.5% of MPFSDB
Indicator in MPFSDB must be either 1 or 2
Procedure code and diagnosis code should be same
Billed amount may differ
*Incorrect Use*
Modifier 62 should not be used when a surgeon acts as an assistant surgeon
Reporting modifier 62 on only one of the surgeons claims
The claim with the 62 modifier will pay at 100%
The other physician's claim without the 62 modifier will deny
Each surgeon billing without modifier 62 will result in incorrect payment

AAPC:  4 Simple Rules for CoSurgeon Documentation:  You should append modifier 62 _Two surgeons_ when two surgeons work together to complete a procedure described by a single CPT® procedure code. To qualify as co-surgeons, the operating surgeons must share responsibility for the surgical procedure, with each serving as a primary surgeon during some portion of the procedure.
To ensure your documentation supports reporting for co-surgeons, follow these four simple rules:

*Each surgeon should document his own operative notes.* Because co-surgeons each perform a distinct part of the procedure, they can’t share the same documentation.
*Each surgeon should identify the other as a co-surgeon.* And both surgeons must submit claims for the same procedure with modifier 62 appended.
*The co-surgeons should link the same diagnosis to the common procedure code.*
*Each surgeon should submit his own claim with his own documentation.*
United's Policy on Multiple Surgeons:   Modifier 66 identifies Team Surgeons involved in the care of a patient during surgery. Each Team Surgeon should submit the same CPT code with modifier 66. Each Team Surgeon is required to submit written medical documentation describing the specific surgeon's involvement in the total procedure. For services included on the Team Surgeon Eligible List (see below), UnitedHealthcare will review each submission with its appropriate medical documentation and will make reimbursement decisions on a caseby-case basis. The Co-Surgeon and Team Surgeon Eligible Lists 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 UnitedHealthcare to be eligible for Co-Surgeon services as indicated by the co-surgeon modifier 62. All codes in the NPFS with the status code indicators "1" or "2" for "Team Surgeons" are considered by UnitedHealthcare to be eligible for Team Surgeon services as indicated by the team surgeon modifier 66. UnitedHealthcare 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 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" section in this policy.  See more at link.


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## Henson65 (Jul 19, 2020)

SharonCollachi said:


> You are correct, otherwise it would more of an assistant at surgery.
> 
> BCBS of North Carolina Policy:   Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative session.  Services by surgeons of different specialties or subspecialties each performing distinct components of a procedure as primary surgeons will be allowed at 120% of the maximum allowance for the primary procedure. Multiple procedure guidelines may apply if additional procedures are performed. *Each surgeon should document his/her distinct operative work in a separate operative report.* Claims from both co-surgeons should report the same procedure code with modifier 62 appended. The total allowance for the operative session will be divided equally between the co-surgeons.  Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty.
> 
> ...



Thank you so much for taking the time to share all of this information. I truly appreciate it! The surgeons are now saying since the CMS says co-surgery also refers to two surgeons working simultaneously together to provide services, this means that they do not have to have unique OP notes since they are both of the same specialty and they worked together under Medicare's definition based upon this quote. We have recently taken over the coding/billing for these two docs and their previous company would just bill whatever they were told to bill without questioning anything. I'm not finding any guidance to say that even when two surgeons of the same specialty work in unison that the documentation requirements are different. I have always been under the impression that the documentation must clearly show what each surgeon did to act as the "primary" surgeon at some point of the intervention.


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## thomas7331 (Jul 20, 2020)

It's my understanding that CMS will not pay two co-surgeons who are of the same specialty.  The Medicare Claims Processing Manual, under billing instructions for modifier 62, states '_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._”'  In addition, the descriptor of the indicator for co-surgeons on the Medicare Physician Fee Schedule is worded "_Indicates services for which two surgeons, each in a different specialty, may be paid_." 

My recommendation in your case, especially given that the two physicians are not documenting different work requiring different skills, is that the physicians might more appropriately bill as surgeon and assistant surgeon rather than as co-surgeons.  In the end, the reimbursement for co-surgeons is only slightly higher than for surgeon and assistant (116% of the PFS for surgeon & assistant vs. 125% for two co-surgeons).


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## Henson65 (Jul 20, 2020)

thomas7331 said:


> It's my understanding that CMS will not pay two co-surgeons who are of the same specialty.  The Medicare Claims Processing Manual, under billing instructions for modifier 62, states '_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._”'  In addition, the descriptor of the indicator for co-surgeons on the Medicare Physician Fee Schedule is worded "_Indicates services for which two surgeons, each in a different specialty, may be paid_."
> 
> My recommendation in your case, especially given that the two physicians are not documenting different work requiring different skills, is that the physicians might more appropriately bill as surgeon and assistant surgeon rather than as co-surgeons.  In the end, the reimbursement for co-surgeons is only slightly higher than for surgeon and assistant (116% of the PFS for surgeon & assistant vs. 125% for two co-surgeons).



Thank you Thomas! I appreciate your feedback. This is exactly the information that I shared with them and that the OP notes support surgeon/assistant. You know the age old argument...but I've always done it this way and never had an issue.....but this is the first time they are using coders and can't understand why there are issues. All i can do is keep fighting the battle and be thankful my boss supports my decision to not fraudulently bill.


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## jmgiles (Jan 8, 2021)

SharonCollachi said:


> You are correct, otherwise it would more of an assistant at surgery.
> 
> BCBS of North Carolina Policy:   Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative session.  Services by surgeons of different specialties or subspecialties each performing distinct components of a procedure as primary surgeons will be allowed at 120% of the maximum allowance for the primary procedure. Multiple procedure guidelines may apply if additional procedures are performed. *Each surgeon should document his/her distinct operative work in a separate operative report.* Claims from both co-surgeons should report the same procedure code with modifier 62 appended. The total allowance for the operative session will be divided equally between the co-surgeons.  Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty.
> 
> ...


I'm so glad that I stumbled across this post. After reading MLN Matters SE1322, I've been trying to figure out how to interpret:

• Modifier 62 - 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 Medicare Fee Schedule Data Base (MFSDB).

I'm taking this to mean that "two surgeons performing parts of the procedure simultaneously" is an exception to the "each in a different specialty rule", is that how you interpret it? How do you think CMS intends for those types of procedures to be reported? I've also come across some of the commercial policies you've referenced. The United policy says "Each surgeon should report the simultaneous bilateral procedures with modifiers 50 and 62". I'm hearing a lot of diffrent viewpoints. What are your thoughts? Thanks


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