Ob-Gyn Coding Alert

Occasionally, ob/gyn surgery requires two surgeons during the same session to perform a difficult procedure or more than one procedure. How can you accurately code for these services? Using the correct codes and modifiers is essential for assuring reimbursement, says Barbara J. Cobuzzi, MBA, CPC, a physician reimbursement specialist and president of Cash Flow Solutions, Inc., in Lakewood, NJ.

Distinct Expertise Required, Same Procedure

Consider a case in which two surgeons are needed for the operation, and each surgeons specialty, talent or expertise is distinct and essential from the others. A woman has been diagnosed with a gynecologic malignancy and needs a total hysterectomy along with removal of the ovaries and bladder and ureteral transplantations. Rather than perform the surgery alone, a gynecologist decides the services of a urologist are also needed. Both surgeons perform the procedure, bringing their expertise to the specialty-specific aspects of the case. The gyn focuses on the hysterectomy and the urologist on the bladder removal and ureteral transplantation.

According to Cobuzzi, what is important in this example is that each surgeons distinct talent is needed to complete the surgery. One surgeon is not assisting the other. Therefore, each specialist will report the procedure 58240 (pelvic exenteration for gynecologic malignancy), along with the -62 modifier. The CPT explains modifier -62 as follows: When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single definitive procedure code.

The rationale behind the -62 modifier is that the main surgeon requires more than just another surgeons assistance for the primary procedure. Both talents are needed. There-fore, the primary procedure must be shared equally between both surgeons. Both will report the surgery, and both the gynecologist and urologist must dictate an operative report that describes, in detail, their parts in the operation. In addition, both should document the other surgeons part, as well as mentioning that the other surgeon also will be dictating a report. Some consultants say that each surgeon should bill 125 percent of his or her fee and expect to be reimbursed about 50 percent of that. Others say each surgeon did not perform more than he or she usually would (should they have performed the procedure separately); in fact, each does slightly less work. In this view, each physician should bill his or her regular fee; the insurance company will generally pay up to 125 percent of the allowable in co-surgery situations and then split this amount in half, giving 66 percent to each surgeon.

The use of modifier -62 will not generally make an allowance for an additional surgeon to act as an assistant because of a payer belief that two surgeons are capable of performing all of the required functions during the surgery. However, under certain circumstances, special consideration will be given for an assistant surgeon, but only if medically justified and documented. The CPT description of this modifier does, however, provide for two primary surgeons to assist each other with additional procedures. It states: If a co-surgeon acts as an assistant in the performance of additional procedures during the same surgical session, those services may be reported using separate procedure code(s) with modifier -80 [assistant surgeon] or -82 [minimum assistant surgeon] added as appropriate. Therefore, it would be acceptable for both surgeons to use the -62 modifier on the primary procedure and for one of the surgeons to attach the -80 or -82 modifier on any additional procedures where only assistance was furnished.

Distinct Expertise Required; Different
Procedures Performed

Occasionally, the ob/gyn is confronted with a situation in which the two surgeons are needed for two specialty-specific procedures performed during the same operative session. For example, if a cancer patient has a radical hysterectomy (58210) performed at the same time as a pancreatectomy (48155), the surgery requires the services of a general surgeon in addition to an ob/gyn.

In this case, Cobuzzi says many consultants believe each surgeon should bill the procedure he or she performed, but no modifier -62 will be added, because the definition of co-surgery in CPT has not been met. However, if the surgery is performed through the same incision (as in the radical hysterectomy and pancreatectomy example above), and since total surgery includes opening and closing, other consultants recommend the surgeon who did not perform the opening and closing should code his or her procedure with a -52 modifier (reduced services). If the -52 modifier is used, the percentage of the procedure performed needs to be provided to the payer.

Note: In a case where complex procedures require more than one surgeon and many assistants, CPT provides modifier -66 to bill for a surgical team. But, according to Cobuzzi, this modifier is reserved only for megasurgeries, such as coronary bypass and transplants that indeed require a team of physicians; thus, it would not apply to typical ob/gyn surgeries.

Editors Note: Next month, OCA will cover the issue of nonphysician providers assisting in surgery.