Neurosurgery Coding Alert

With carriers paying 62 percent on co-surgery cases, 20 percent on assistant surgeries, and 15 percent for non-MD assistants, the wrong modifier can cut your pay big time -- meaning you better keep certain rules in mind.

The hang-up: "Choosing between the co-surgery and assistant surgeon modifiers can be a confusing matter because physicians often do not understand the difference themselves," says Beth Thomsen, department billing coordinator for Neurosurgery/Plastic and Reconstructive Surgery with University of Toledo Physicians LLC. "One surgeon may dictate an operative report as though it's a co-surgery, but the supposed co-surgeon feels that he or she acted as an assistant only."

Solution: Focus on what the physician did during the case and the physicians' coordination and documentation, Thomsen recommends. Read on for tips on ensuring the surgeon's work -- not his dictation -- leads you in the right direction every time.

Encourage your providers to clearly document their roles so you'll know how to report the case. The simplest way to approach your coding is to treat each physician's portion as a separate procedure.

Once you know the codes to report you must determine whether you're dealing with surgeons working independently on separate procedures, a co-surgeon, or an assistant surgeon. And in some cases, you'll also need to account for a non-physician practitioner's (NPP) work with one or both surgeons.

A case designated as having co-surgeons means that two surgeons perform distinct, separate parts of the same procedure. Append modifier 62 (Two surgeons) for each physician to the code for the single procedure that he or she accomplished.

Both surgeons dictate their own operative notes to describe their roles in that single procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions. "The sum of the two operative notes added together describes the CPT code being billed and coded," she says. Medicare pays each surgeon 62 percent of the billed code.

Example: Dr. A performs the approach and Dr. B performs the definitive procedure. Dr. A would perform and dictate his portion, then transfer the case and dictation to Dr. B for the remainder.

Caution: You can report modifier 62 for only one primary procedure and its related add-on codes for each surgeon. If the second surgeon continues to help with additional aspects of the case, you're coding for an assistant surgeon instead of a co-surgeon.

You're looking at assistant surgery when physicians work together on a case and one performs the majority of the procedure while the other assists in some capacity.

"There is only one operative note dictated by the primary surgeon," Cobuzzi says.

The surgeon of record is listed as the primary surgeon and identifies the assistant surgeon and his work in the dictation. "The second surgeon is listed on this operative note as the assistant surgeon, but he has no role in the dictation of the documentation," Cobuzzi explains.

If your case qualifies as allowing assistant surgery, you'll choose the appropriate modifier based on individual circumstances:

• When the physician assisted in the majority of the case, use modifier 80 (Assistant surgeon)

• When the physician assisted for less than the majority of the case, report modifier 81 (Minimum assistant surgeon)

• When a qualified resident surgeon isn't available to serve as the assistant, choose modifier 82 (Assistant surgeon [when qualified resident surgeon not available]).

Medicare pays the assistant surgeon 20 percent of the billable amount when you report modifiers 80, 81, or 82.

Non-physician practitioner (NPP) involvement adds another dimension to your coding. An NPP (such as a physician assistant or nurse practitioner) may submit a claim for his services if he is credentialed by the carrier to do so.

Check payer guidelines: When you code for an NPP, report according to the payer's guidelines.

• For Medicare, append modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to all the surgeon's procedures for which the physician assistant provided surgical help.

• Other payers do not recognize modifier AS and might have different guidelines, so verify the correct way to report the NPP's service before completing your claim.

Non-physician practitioners who act as assistants during surgery should bill with modifier AS and are eligible for a 15 percent reimbursement of the primary surgeons allowable, if procedures are eligible for assistance as determined by CMS.

Test yourself: Ready to test your skills? Stay tuned for next month's issue of Neurosurgery Coding Alert, when you can try your hand at coding a multi-surgeon case straight from one of our readers.