Neurosurgery Coding Alert

Coding can become tricky when two surgeons work together during the same surgery. Medicare and CPT specify strict instructions for co-surgery billing and, depending on the procedure(s) involved, documentation requirements to justify billing for two surgeons can vary. Proper use of modifiers and thorough record-keeping go a long way to guarantee proper and timely payment.

Modifier -62 (Two surgeons) indicates that the individual skills of two surgeons are required during the same surgical procedure. In such cases, each surgeon codes independently of the other, with modifier -62 appended to the applicable CPT procedure code (s).

Section 15044 of the Medicare Carriers Manual (MCM) further specifies that co-surgeons share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons, and are frequently but not necessarily of different specialties. The MCM further specifies that co-surgeons share pre- and postoperative responsibility for the patient.

For instance, a neurosurgeon and otolaryngologist may work side-by-side during the approach"" portion of a skull base surgery (e.g., 61590, Infratemporal pre-auricular approach to middle cranial fossa [para-pharyngeal space, infratemporal and midline skull base, nasopharynx], with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery). In this case, each surgeon reports 61590-62.

Although two heads are generally better than one, neither CPT nor CMS allows billing for co-surgeons in every situation. According to the Physician Fee Schedule, surgical procedures fall into one of four categories with respect to co-surgeons:

1. Procedure for which modifier -62 is allowed but supporting documentation is required to establish medical necessity for two surgeons, regardless of specialty: This category includes some craniectomies (e.g, 61526 and 61530), craniotomy 61533-61543 and most skull base surgery approach codes (61580, 61582-61598). The documentation should show what special circumstances or skills required the surgeons to share responsibility for the patient. For example, the extraordinary duration of some skull base surgeries may require that two surgeons work in shifts, allowing each to scrub out while the other continues the procedure. Or they may work simultaneously but perform distinct components of a procedure.

These procedures are identified with a ""1"" in column U (labeled ""co-surg"") of the Physician Fee Schedule.

2. Procedures for which modifier -62 is allowed as long as each surgeon is of a different specialty: Two neurosurgeons working together cannot report modifier -62 for these codes. Examples of such procedures include laminotomy/laminectomy codes 63001-63048 and diskectomy 63075-63078.

These procedures are identified with a ""2"" in column U of the fee schedule.

3. Procedures for which modifier -62 is never allowed: Such procedures are identified by a ""0"" in column U of the fee schedule and include endovascular therapy (61624-61626) and stereotactic procedures 61790-61795, among others.

4. Procedures for which the concept of co-surgeons does not apply and for which modifier -62 is therefore inappropriate: These procedures are noted by a ""9"" in column U. Examples include supplemental ""V"" and ""S"" codes not normally used in neurosurgery.

Payers, both Medicare and private, generally follow the guidelines set forth in the fee schedule (although you may want to ""double-check"" with private payers). Therefore, before appending modifier -62 to any procedure code, check the fee schedule to be sure the modifier is allowed and, if so, what documentation is necessary to justify the claim.

Note: To download the latest version of the CMS Physician Fee Schedule, visit the CMS Web site at http://www.cms.gov/physicians/pfs/default.asp and select the link for ""Physician Fee Schedule Relative Value File.""

Medicare and many other payers reimburse procedures coded with modifier -62 at 125 percent of the regular fee schedule amount, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a coding and reimbursement consulting firm in Lakewood, N.J. The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the standard fee.

Returning to the earlier example of the neurosurgeon and otolaryngologist working together during the skull surgery approach, each surgeon would receive 62.5 percent of the fee schedule reimbursement for 61590, or about $1,633 each on average:

72.18 relative value units for 61590 x national conversion rate of $36.1992 = $2,612.86
$2,612.86 x 1.25 for modifier -62 = $3,266.07
$3,266.07 / 2 = $1,633.03

Co-surgeons must work in synchronicity in both the operating room and when coding: Each surgeon must dictate his or her own operative report and identify the other surgeon as a co-surgeon, Cobuzzi advises. And, each surgeon must submit his or her own CMS-1500 claim form with the required documentation, using his or her own personal identification number (PIN). ""Neurosurgery doesn't recognize subspecialties,"" says Gregory J. Przybylski, MD, an AMA RUC member. ""So if two physicians have the same tax ID numbers [because they are from the same practice, for instance], they will be considered one person from a payer standpoint and won't be able to use modifier -62.""

Co-surgeons will not necessarily file identical claims. For example, although a neurosurgeon and otolaryngologist may work together during an approach, the neurosurgeon will likely perform the definitive portion of skull base surgery alone. In this case, each surgeon reports 61590-62, but the neurosurgeon will also report the definitive procedure (e.g., 61606, Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft) appended with modifier -51 (Multiple procedures).

Just because two surgeons operate on the same patient during the same operative session does not mean that modifier -62 is appropriate. The MCM section 4828 notes, ""If surgeons of different specialties are each performing a different procedure (with specific CPT-4 codes [e.g., ""sequential"" surgery]), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services.""

For example, if the otolaryngologist performs approach 61590 without the neurosurgeon's help, and the neurosurgeon performs the definitive procedure 61606 without the otolaryngologist's help, each surgeon should report his or her portion of the surgery independently, with no modifiers appended. If the neurosurgeon performs additional procedures (e.g., 62272*, Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter] for regulation of cerebrospinal fluid pressure), the multiple-procedures rules apply.

In a second example, the neurosurgeon performs a decompressive lumbar laminectomy L3-S1 with foraminotomies and lateral recess decompression, which is followed by lateral mass fusion with use of morselized autograft by an orthopedic surgeon. In this case, each surgeon performs a distinct procedure as appropriate to his or her specialty, without aid from the other surgeon. Therefore, both the neurosurgeon and orthopedic surgeon should report his or her portion separately even though all procedures were performed using the same incision and closure.

The neurosurgeon reports 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis], single vertebral segment; lumbar) for the decompression at the first level and 63048 for each additional segment. The orthopedic surgeon reports the fusion and bone grafts independently, using 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) and 20937 (Autograft for spine surgery only [includes harvesting the graft]; morselized [through separate skin or fascial incision]).