Neurosurgery Coding Alert

Question: Recently, our neurosurgeon worked with an orthopedic surgeon to perform spinal fusion with placement of instrumentation. Both surgeons dictated their own operative reports, and each surgeon reported 22612 (for the arthrodesis) and 22842 (for the instrumentation) with modifier 62 appended to show that they acted as co-surgeons. Both doctors received denials. How should we have billed this?

California Subscriber

Answer: There are a number of potential problems with the claim, the most important of which is that you should never report modifier 62 (Two surgeons) with spinal instrumentation codes 22840-22848 or 22850-22852. CPT includes these instructions in the notes prior to the instrumentation code listings.

You may, however, report modifier 80 (Assistant surgeon), if the situations warrants. CPT does not prohibit using modifier 80 with instrumentation codes, and the Medicare physician fee schedule database allows for modifier 80 with instrumentation codes as long as the operating surgeons are of different specialties.

In this case, both surgeons will want to report 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) with modifier 62 -- assuming that the surgeons truly did act as co-surgeons on this procedure.

For the instrumentation, one surgeon will report 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments) with no modifier, and the second surgeon will report 22842 with modifier 80.

Both surgeons should dictate their own operative reports, and each should identify the other as a co-surgeon on the arthrodesis, as well as the second surgeon's status as an assistant on the instrumentation placement.

But a surgeon billing as an assistant surgeon (using modifier 80) will not receive as much reimbursement as if he were paid as a co-surgeon (using modifier 62).

Even more fundamental, however, is the issue of medical necessity. Your documentation must justify the rationale for having two surgeons working together on the fusion and instrumentation placement. Were there unusual circumstances involving the patient or procedure? Did each surgeon have a different area of expertise required to complete the procedure?

If you cannot justify the need for both surgeons, the payer will likely not pay the additional expense of having a second surgeon in the operating room, regardless of the modifiers you append.