Gastroenterology Coding Alert

Question: A gastroenterologist who "assisted" in several surgeries was involved in a colectomy (44140) last week. The week before it was an enterectomy (44120) and a repair of hernias (49560). Is this separately billable and, if so, is he considered an assistant surgeon or a co-surgeon. How should we bill these services?

Kentucky Subscriber
 
 
Answer: Co-surgery is when two surgeons are required to perform distinct parts of the same procedure, says Cynthia Thompson, CPC, senior consultant with Gates, Moore & Co., a healthcare consulting firm in Atlanta. She cites procedures from other specialties as examples, such as surgery on the spinal cord that will require the services of both a neurosurgeon and an orthopedic surgeon. "With co-surgery, each surgeon is responsible for a distinct portion of the procedure," Thompson explains. "One way to look at it is that the surgeons take turns being in charge of the procedure; they swap roles."
 
If a gastroenterologist is involved in a co-surgery, both surgeons bill the same procedure code with modifier -62 (two surgeons) attached. The operative report should be sent in with the claim to document what each surgeon did. Medicare (and most other payers) will pay each surgeon 62 percent of the allowable fee for the procedure. Some payers will require that the surgeons be from two different specialties, but other payers will require documentation to establish medical necessity if the surgeons are from the same specialty.
 
An assistant surgeon does not have to be a surgeon and is not performing a distinct part of a procedure, states Thompson. "An assistant surgeon does not take on the responsibility for a procedure," she explains. "He or she is helping the other surgeon by performing tasks like suturing or making an incision."
 
If a gastroenterologist is an assistant surgeon, he should attach modifier -80 (assistant surgeon) to the same procedure code that the surgeon reports. Most payers usually will not require that the operative report be sent with the claim. The assistant surgeon will receive 16 percent of the allowable fee for the procedure.
 If these are Medicare patients, you also need to check the Medicare Physicians Fee Schedule database to see if a co-surgery or assistant surgeon can be billed with the procedure. According to Medicare transmittal number 1678 dated Sept. 22, 2000, field 23 of the Medicare Fee Schedule is the assistant-at-surgery field, and the indicators for this area are as follows:

0 -- Payment is restricted for assistants at surgery unless documentation is submitted that establishes medical necessity.

1-- Statutory payment restrictions apply, and assistants at surgery are not paid.

2 -- No payment restrictions apply, and assistant at surgery is paid.

Field 24 of the Medicare Fee Schedule is the co-surgery field, and the indicators for this area are as follows:

 
0 -- Co-surgeons are not permitted for this procedure.
 
1 -- Co-surgeons could be paid; supporting documentation required to establish medical necessity.
 
2 -- Co-surgeons permitted; no documentation needs to be submitted if two-specialty requirement is met.

 
Payers will differ on whether gastroenterologists are considered surgeons and whether they can even bill for a co-surgery procedure. Most payers will allow two gastroenterologists who are performing a PEG tube placement (43246) to bill the procedure as a co-surgery with modifier -62. However, National Heritage Insurance Company, the Part B carrier for California, will not allow two gastroenterologists to bill a PEG tube placement as a co-surgery and requires that it be billed as an assistant surgery with modifier -80. The assistant surgeon in this procedure is typically the gastroenterologist who handles the preparation and treatment of the incision into the abdomen.