Gastroenterology Coding Alert

Forfeit your payment if both physician’s claims don’t reflect the modifier use.

When your gastroenterologist teams up with another physician during a procedure, you’ll need to attach the right modifier to ensure proper reimbursement. Your multi-provider claims can go downhill if you mess up your coding by assigning the wrong modifier(s). We give you the lowdown on determining whether modifier 62 (Two surgeons) is your best bet for a successful claim with these  expert tips.

Tip 1: Prepare for the Pre-Requisites and Restrictions for Modifier 62

According to the Modifier 62 Fact Sheet of WPS Medicare, you can bill for modifier 62 when “Two surgeons are required to perform a specific procedure.” Following rules govern the usage:

Allowed if: Two physicians (each in a different specialty) are required to perform a specific procedure for the patient; or two surgeons (same or different specialty) are each performing parts of the same procedure simultaneously; or both physicians bill the same procedure code appending modifier 62.

Append the modifier 62 to each physician’s procedure when the physicians perform distinct, separate portions of the same procedure. Modifier 62 tells you that each physician completed a single procedure within the overall surgery. Look for a hint in the operative notes. Both physicians should dictate their own op notes to describe their roles in that single procedure. Modifier 62 is your best bet for insertion of a PEG tube when one gastroenterologist performs the endoscopic portion and another gastroenterologist (or physician) performs the percutaneous puncture portion on the abdomen.

Not allowed if: One surgeon is acting as an assistant surgeon; or both surgeons are acting simultaneously, but not working on the same procedure; or there are more than two primary surgeons.

In terms of payments, the providers should discuss the distribution of fees and arrive at an agreement between themselves before submitting claims for the service. Information about the percentage of distribution should appear on the claims. If no fee is indicated, CMS states that 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.

Important: Both surgeons need to report the same surgery code with the modifier 62. If one provider bills with a modifier 62 and the other bills with no modifier, the payer will suspend the claim for review or will deny. Make sure you provide detailed documentation with the claims. Global surgery rules apply to each of the physicians participating in a co-surgery.

Tip 2: Firm Up Your Resolve With This Scenario

Scenario: Your gastroenterologist is the primary caregiver for a patient with severe weight loss. He goes to the hospital to meet the patient, who is weak from starvation. With the help of another surgeon, the GI inserts a PEG tube.

The main key in a multi-provider scenario is to treat each physician’s work as a separate activity. However, deciding when to report a case as co-surgery, assistant surgery -- or something else -- has more to it than meets the eye. Find out what with this expert’s advice.

In the scenario given, you should report 43246 ( Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube) for the PEG placement. Then, you would use 994.2 (Effects of hunger) with 43246 to describe the diagnosis. Finally, you should append modifier 62 to 43246 to show that two gastroenterologists performed the insertion. Both providers should complete a report of the services they performed, both would use 43246-62 to file their claims, and they should each be paid half of 125 percent of the usual reimbursement of 43246.

Catch: Note that Medicare does NOT recognize two gastroenterologists reporting 43246-62 — only two different specialists. An appeal by American Society for Gastrointestinal Endoscopy is pending with CMS for this policy.

Tip 3: Identify Your Code’s Co-Surgery Indicator

You should be careful to know when modifier 62 applies to the code you wish to report. Medicare won’t pay for co-surgeries with just any code in the practice, so don’t bother appending the modifier where it doesn’t fit.

Check your Medicare physician fee schedule database to confirm that the procedure you wish to report qualifies for modifier 62. Otherwise, your physician cannot code and bill as co-surgeon for that procedure. To be eligible for payment, make sure that your procedure codes have either a Medicare co-surgery indicator of “1” or “2.”. The coverage dictates a pricing of 125 percent of the allowable, which is a 50-50 split between both surgeons (or 62.5 percent for each surgeon).

If you find a code carries a co-surgery indicator of “1,” you must supply documentation to establish medical necessity for two surgeons. Only when you establish medical necessity clearly will a payer consider additional reimbursement. You should present which circumstances in the procedure requires special skills or expertise by two surgeons sharing a responsibility.

A “2” indicator in the co-surgery column means that you may append modifier 62 as long as each of the operating surgeons is of a different specialty or of the same specialty but with different expertise.

Medicare will not allow modifier 62 for a procedure with a “0” indicator, which means that you are not allowed to bill for co-surgeons.

Mind this: You may find cases when you find a “9” in the co-surgery column. If so, Medicare will not consider modifier 62 applicable to this code, so don’t bill with the modifier.

Tip 4: Avoid the Modifier 51 Trap

It’s easy to fall into the lure of using modifier 51 (Multiple procedures) when you’re coding for multiple procedures during the same operative session, but you could end up in the gutters if you’re not careful enough.

Why: Modifier 51 tells you that a physician was present performing multiple procedures. If a physician is not physically present for multiple procedures in a surgical case, it’s not appropriate to indicate that he was by using modifier 51.