General Surgery Coding Alert

Question: Our surgeon performed the bilateral pelvic lymph node dissection and omentectomy during a total abdominal hysterectomy. Should we bill his portion as an assistant surgeon or a co-surgeon? Or, should we report the lymph node excision separately?


Pennsylvania Subscriber

Answer: Proper coding in this case depends both on the general surgeon's level of involvement and on the documentation he provides.

To qualify as co-surgeons, two surgeons must perform "distinct components" of a single identifiable CPT procedure, according to AMA guidelines.

Your description indicates that your surgeon and the other surgeon did perform distinct components of the surgery during a single procedure, 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]). In this case, each surgeon should report 58210 with modifier -62 (Two surgeons) appended.
 
To further meet the requirements of modifier -62, however, each surgeon must dictate and provide his own operative notes outlining the portion of the surgery that he provided. Without this supporting documentation, your surgeon will not qualify as a co-surgeon.

If your surgeon only acted as a "second pair of hands" in the operating room and assisted the primary surgeon (such as an ob-gyn), you would report 58210 with modifier -80 (Assistant surgeon) appended.

In this case, your surgeon does not have to provide his own operative notes, but you should be aware that payment is much less for an assistant surgeon than for a co-surgeon.

What you should definitely not do is allow the ob-gyn to report a separate hysterectomy without lymph node excision (58150) and bill separately for the lymph node excision for your surgeon. This would constitute unbundling, which would likely result in denied claims for both surgeons and possibly even allegations of fraud.