Ob-Gyn Coding Alert

4 tips break down what documentation both physicians should have.

When a urologist and ob-gyn perform services on the same patient during the same surgical session, you have to be extra vigilant about whether to apply modifier 62 and what documentation your physician provides, or you could face a denial that's complicated to appeal.

Don't miss: Tackle these two scenarios -- one where the physicians assist each other and one where the physicians perform distinct parts of the procedure -- and discover when you should apply modifier 62.

Suppose a urologist and an ob-gyn perform a bladder suspension and a hysterectomy at the same surgical session.

Solution: Both physicians should report 58267 (Vaginal hysterectomy, for uterus 250 grams or less; with colpo-urethrocystopexy [Marshal-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) or 58293 (Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control).

You should report this claim as two surgeons (modifier 62). In other words, "each surgeon is going to code the main procedure with modifier 62," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, charge capture manager for the University of Washington Physicians in Seattle.

Reason: If one specialist performs one part, or component, of a procedure, and another specialist is performing another part of the procedure, payers will consider them co-surgeons. This means the physicians should each report the same CPT code with modifier 62, says Veronica Antonelli, CPC, coding and compliance coordinator for Women's Care Florida/PBS. Using modifier 62, each surgeon will receive 62.5 percent of the allotted fee for the service, unless the surgeons agree to a different split in advance, which they would communicate to the payer.

But what if the services performed by the two specialists aren't represented in a single code?

"If two surgeons are working on performing two distinct procedures during the same surgical session, you can't use modifier 62 and call the surgery a co-surgery because the physicians won't be reporting the same code," Antonelli says. In this case, "each physician should report the code for the service he provided, without a modifier."

Example: A patient undergoes a vaginal hysterectomy and a sling procedure. In this case, each surgeon should report a separate code(s) to represent his individual service(s).

The urologist would report 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]), and the gynecologist would report either 58260 (Vaginal hysterectomy, for uterus 250 grams or less) or 58262 (... with removal of tube[s], and/or ovary[s]). Modifier 62 no longer applies because the surgeons report two separate codes.

Upside: When two separate codes are used, each physician should receive the full fee allotted for the service he reports.

When two surgeons work together to perform one procedure, each physician's individual documentation requirements can get jumbled. Make sure your urologist isn't passing the documentation buck and that he or she knows to follow these four tips when you submit claims with modifier 62.

Tip 1: Each physician should identify the other as a co-surgeon. Make sure the other physician is billing with modifier 62. A lot of confusion can arise when physicians from different practices are reporting the same procedure.

You may find yourself in a situation where one physician may report the other physician's work as that of an assistant surgeon, in which case the claims would not correspond. This means a denial will hit your desk. One surgeon cannot simply indicate the other as the co-surgeon. Both physicians must submit claims for the same procedure, both with modifier 62.

Tactic: You can accomplish this with a simple courtesy call to the other physician's billing or coding department, experts say.

Tip 2: Each physician should document her own operative notes. When surgeons are acting as "co-surgeons," it is implied that they are each performing a distinct part of the procedure which means they can't "share" the same documentation, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

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

Tip 3: Each physician must link the same diagnosis code to the common procedure code. Though this require-ment may seem obvious, if two physicians serve as co-surgeons to perform one procedure, the diagnosis code(s) they link to the CPT code should be the same -- and it almost always will be, Parks says. Before submitting a claim with modifier 62, someone in the practice must confirm that both claims have the same ICD-9 code(s).

Tip 4: Each physician must submit his own claim with his own documentation. Because claims for co-surgeons of the same specialty can come under scrutiny, each physician must diligently detail both the work he performed and the work the other physician performed.

Good advice: Many physicians submit a letter to the carrier detailing the reason for two surgeons.

Because modifier 62 requires so much claims coordination, get a game plan together outlining what each surgeon is going to do to complete the procedure and how they are both going to document and code for it. This is one surefire way to improve your chances of getting the reimbursement you deserve on the first try.