General Surgery Coding Alert

Coding can become tricky when two surgeons work together during the same surgery. Medicare and CPT specify strict instructions for co-surgery billing, and if you dont coordinate the two physicians claims carefully, one surgeon could lose his or her reimbursement entirely.

First You Must Know if Its Allowable

Modifier -62 (Two surgeons) indicates that the individual skills of two surgeons are required during the same surgical procedure. In such cases, each surgeon codes independently of the other, with modifier -62 appended to the applicable CPT procedure code(s), says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
Section 15044 of the Medicare Carriers Manual (MCM) further specifies that co-surgeons share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons and are frequently but not necessarily of different specialties. The MCM further specifies that co-surgeons share pre- and postoperative responsibility for the patient. 
 
Although two heads are generally better than one, neither CPT nor CMS allows billing for co-surgeons in every situation. Surgical procedures fall into one of four categories with respect to co-surgeons, as outlined in the Physician Fee Schedule database:
 
1. Procedures for which modifier -62 is allowable, but supporting documentation is required to establish medical necessity for two surgeons, regardless of specialty: This category includes embolectomy/thrombectomy (34001-34490), direct aneurysm repair or excision and graft insertion for aneurysm (35001-35112), and esophageal repairs (43300-43425). Your documentation must show what special circumstances or skills required the surgeons to share responsibility for the patient. For example, the extraordinary duration of a trauma surgery may require that two surgeons work in shifts, allowing each to scrub out while the other continues the procedure. Or they may work simultaneously but perform distinct components of a procedure.

These procedures are identified with a 1 in column U (labeled co-surg) of the Physician Fee Schedule database.

 2. Procedures for which modifier -62 is allowable as long as each surgeon is of a different specialty: Examples of such procedures include endovascular abdominal aortic aneurysm repair 34800-34832 and transluminal atherectomy 35480-35485.
 
These procedures are identified with a 2 in column U of the fee schedule database.
 
3. Procedures for which modifier -62 is never allowable: Such procedures are identified by a 0 in column U of the fee schedule database and include lesion removal 11400-11646 and breast incision/excision 19000-19272, among others.
 
4. Procedures for which the concept of co-surgeons does not apply, and for which modifier -62 is therefore inappropriate: These procedures are noted by a 9 in column U of the fee schedule database. Such procedures are relatively rare and include minor services such as naso- or oro-gastric tube placement 43752.

General surgery coders should keep in mind that both Medicare and private payers generally follow the guidelines set forth in the fee schedule database (although you may want to double-check with private payers). Therefore, before appending modifier -62 to any procedure code, check the fee schedule database to be sure the modifier is allowable and, if so, what documentation is necessary to justify the claim.
 
Note: To download the latest version of the CMS Physician Fee Schedule database, visit the CMS Web site at http://www.cms.gov.

Coordinate Your Billing

 Medicare and many other payers reimburse procedures coded with modifier -62 at 125 percent of the regular fee schedule amount. The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the standard fee, says Stephanie Collins, CPC, healthcare consultant with Gates, Moore & Company in Atlanta.
 
For instance, a general surgeon and an orthopedic surgeon work together during an anterior fusion of the spine, with the general surgeon performing the approach and the orthopedic surgeon performing the fusion. In this case, each surgeon would receive 62.5 percent of the fee schedule reimbursement for 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2), or about $829 each on average:
 
36.07 relative value units for 22554 x national conversion rate of $36.7856 = $1,326.86
  $1,326.86 x 1.25 for modifier -62 = $1,658.58
  $1,658.58 / 2 = $829.29

 Note: Because the surgeons will be paid equally, if one surgeon deserves more reimbursement than the other, the surgeons must work out a payment solution. 
 
Co-surgeons must work in synchronicity both in the operating room and when reporting the services they provide: Each surgeon must dictate his or her own operative report and identify the other surgeon as a co-surgeon (if one physician bills as an exclusive surgeon, i.e., without modifier -62, the other physician will have nothing to bill).
 
Including a brief explanation for the need for co-surgeons will help to avoid denials and reimbursement delays. Because each surgeon performs a distinct part of the procedure, they cant share the same documentation, says Linda Parks, MA, CPC, CCP, coding specialist for GI Diagnostics Endoscopy Center in Marietta, Ga. Each physician should provide a note detailing what portion of the procedure he or she performed, how much work was involved, and how long the procedure took. 
 
And, each surgeon must submit his or her own CMS-1500 claim form with the required documentation, using his or her own personal identification number (PIN), although partners in the same practice who may have the same PIN can bill as co-surgeons as long as documentation clarifies the situation.

Two Surgeons Wont Always Mean Modifier -62

 Just because two surgeons operate on the same patient during the same operative session does not mean that modifier -62 is appropriate, Jandroep says. The MCM, section 4828, states, If surgeons of different specialties are each performing a different procedure (with specific CPT-4 codes [e.g., sequential surgery]), neither co-surgery nor multiple-surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple-procedure rules apply to that surgeons services.
 
For example, a motor vehicle accident patient requires emergency surgery for serious internal injuries of the chest and abdomen, as well as subdural cranial hematoma. In this case, a general surgeon, an orthopedic surgeon and a neurosurgeon may all attend to the same patient during the same operative session, but as long as each performs his portion without explicit aid from the others, each should report his or her portion of the overall surgery independently, with no modifiers appended. If the general surgeon performs multiple procedures, however, the standard multiple-procedures rules apply.