General Surgery Coding Alert

Question: In our-practice, two surgeons work together to place a percutaneous gastrostomy tube. One surgeon places the G-tube, while the other surgeon checks for placement laparoscopically.

Virginia Subscriber

Answer: According to the latest Medicare Physician Fee Schedule Relative Value File, CMS assigns a "0" modifier indicator to 43246 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) for assistants at surgery. This means "Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity" -- but it does not rule out payment with modifiers 80 (Assistant surgeon) or 82 (Assistant surgeon [when qualified resident surgeon not available]).

Similarly, the Relative Value File assigns a "2" modifier indicator for modifier 62 (Two surgeons), which designates "Co-surgeons permitted and no documentation required if the two-specialty requirement is met."

In other words, you should be able to report 43246 with modifier 80, 82 or 62 -- as long as you show medical necessity for the procedure and, in the case of co-surgeons, establish that the surgeons are of different specialties.

In your case, the problem likely arises because both surgeons performing the procedures are of the same specialty and, more precisely, share the same skill set. CMS will argue that having two surgeons with the same skill set to complete the procedure is unnecessary, and that Medicare shouldn't have to pay an increased fee to reimburse the second (unnecessary) surgeon.

General surgeons and gastroenterologists frequently perform G-tube placement without assistance, which raises the obvious question, "What is the medical necessity of having two surgeons perform this service that is usually performed by one?" Only if you can answer this question with solid documentation can you expect Medicare to reimburse for a second physician.