Medicare Compliance & Reimbursement

Know the nuances for coding and classifying additional surgeons.

Operative reports aren’t easy to compile and can cause all sorts of coding problems. Plus, if you add an extra surgeon or two — or more — to the mix, it can be even more complicated. That’s why it’s critical that you know the modifier options and make the best choice for your claims.

Details: Five modifiers, some more well known than others, offer differentiation depending on the surgery circumstances. Whether two surgeons performed the surgery or a team worked together, there is a coding solution that best fits your claim.

Use This Modifier When 2 Surgeons Are Required

When two surgeons cooperate to perform a surgery within the same body cavity and with a single goal, each of them applies their own expertise to achieve that single goal. At the same time, they assist and complement each other.

Another name for this is co-surgery, which “also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (e.g., heart transplant or bilateral knee replacements),” notes Part B Medicare Administrative Contractor (MAC) Novitas Solutions’ modifier 62 fact sheet.

To bill for co-surgery, both surgeons must bill using the same CPT® code(s) and append modifier 62 (Two surgeons). And remember, the procedure and diagnosis codes must be the same for co-surgery to work, according to Novitas.

Documentation: Co-surgery billing requires that each physician document their own op notes. When two surgeons use modifier 62, it implies they are each performing a distinct part of the procedure — which means they can’t share the same documentation.

Each physician should provide notes detailing what portion of the procedure they performed, how much work was involved, and how long the procedure took. Consequently, a brief explanation of the need for co-surgeons will help to avoid denials and reimbursement delays.

Caveat: However, if a singular operative report is used for both physicians (same practice/same Tax ID number with different UPIN number), both physicians must confirm and sign off on this operative report, and each specific service provided must be spelled out and identified who provided what service in a descriptive explanation, explains Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, coding quality & education department, and member of AAPC’s Certified Cardiology Coder steering committee. The word “we” shouldn’t be used, and attaching specific physicians’ names to the specific procedures is recommended.

Tip: Make sure you review the Medicare Physician Fee Schedule Database (MPFSDB) guidance as well as the procedure codes’ co-surgery indicators.

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 require special skills or expertise by two surgeons sharing a responsibility.

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

Attach Modifier 66 for Team Surgery

If more than two providers of different specialties perform work during the same surgery, often using complex surgical equipment, you’ve got yourself a team. When this happens, you’ll append modifier 66 (Surgical team) to the surgical code(s).

Definition: “A surgical team is … several surgeons of different specialties involved in one case,” relates Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

Some circumstances require providers to perform highly complex procedures under the surgical team banner, and the documentation must back up the codes used, warns Part B MAC Palmetto GBA modifier 66 fact sheet.

Providers must ensure that the CPT^® code is modifier 66-approved. You should “refer to the Medicare Physician Fee Schedule Database (MPFSDB) to determine if CPT^® modifier 66 is applicable to a particular surgical CPT^® code. Note that team surgeries are normally limited to organ transplants and re-transplants,” advises Palmetto.

When you are coding for team surgery, the medical record must show medical necessity for having a team of surgeons working together, because team surgeries are paid for on a “by-report” basis.

Action: Physicians must provide details in their documentation describing the procedure performed and stating that they were part of a team. Each provider reports the same procedure code(s) with modifier 66 attached. This tells the payer that the amount for the procedure should be divvied up between a team of providers instead of being paid to just one.

Tip: This process is identical to the co-surgery requirements; it just involves a larger team.

TEAM SURG: Coders should check the MPFSDB before using modifier 66, recommends Palmetto. Because if you see either the “0” or “9” in the TEAM SURG column, you should never apply 66 to that code. The zero indicates that team surgeons are not permitted for the procedure, and the nine means the concept does not apply.

If you find a “1” in the TEAM SURG column, Medicare may allow modifier 66 with supporting documentation that establishes medical necessity for the surgical team. If you find “2” in the TEAM SURG column, Medicare will permit modifier 66 with that code.

Utilize These Modifier Options for the Assist

The primary surgeon may use an assistant surgeon for several reasons, such as a particularly complex procedure or patient condition. But remember, the assistant surgeon works under the direct supervision of the principal surgeon.

“Medicare requires the primary surgeon to list the assistant surgeon in the operative report, and make some notation within the procedure description regarding how the assistant was involved,” explains Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebraska.

Definition: “An ‘assistant at surgery’ is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The ‘assistant at surgery’ provides more than just ancillary services,” Novitas says.

CPT^® offers practices three assistant-surgeon modifiers. They include:

• 80 (Assistant Surgeon)
• 81 (Minimum Assistant Surgeon)
• 82 (Assistant Surgeon when qualified resident surgeon is not available).

Important: The distinction between modifiers 80 and 81 is whether the assistant surgeon participates during the entire procedure, or just a portion of it; however, modifier 80 scenarios are the most common. Reserve modifier 82 for cases in a teaching hospital when a qualified resident is not available, so an assistant surgeon participates in the entire procedure.

Payment: Medicare will pay for a surgical assistant only when the procedure performed is authorized for an assistant, and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP), or a clinical nurse specialist (CNS).

When a PA, NP, or a CNS assists at surgery, attach modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to the surgical code along with modifier 80, indicates the Novitas fact sheet.

Without modifier AS, modifiers 80, 81, and 82 indicate that a physician was the surgical assistant. Claims you submit that include modifier AS without modifier 80, 81, or 82 will be returned to you.

Rules: Before billing for an assistant at surgery, check the MPFSDB guidelines and the ASST SURG column to verify that the procedure(s) allows an assistant.

Remember these designations in the ASST SURG column:

• “0” indicates that Medicare will allow payment (upon satisfactory review) for an assistant at surgery if you submit supporting documentation to establish medical necessity.
• “1” tells you that an assistant at surgery will never be paid. You should never apply modifiers 80 or AS to these codes.
• “2” means that Medicare will routinely pay for the procedure in conjunction with an assistant surgeon. Append modifier 80 and/or AS to these codes to indicate that an assistant surgeon was involved with the case.
• “9” indicates that the assisted surgery concept does not apply. You should never attach modifiers 80 or AS to these codes. Many of the N status or noncovered codes carry a 9 in the assistant at surgery column.

Bottom line: Be aware that payment is much less for an assistant surgeon than for a co-surgeon. For an assistant surgeon, Medicare allows 16 percent of the total allowed amount, and commercial payers vary from 16 to 50 percent of the primary allowed amount.

Resource: Find more Medicare advice on modifiers at  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf.