Ob-Gyn Coding Alert

Two surgeons often participate in complicated ob/gyn surgeries. But their degree of participation, the complexity of the procedure and the way the procedure is coded impact reimbursement. Modifier -62 (two surgeons) results in optimum reimbursement when more than one surgeon is involved, but physicians and coders must understand its proper use and apply it only in genuine cases of dual surgery.

Make Sure Its Co-surgery

Per CPT 2000, modifier -62 is intended for use only when two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure. If the second surgeon acts as a first assistant, rather than a co-surgeon, modifier -80 (assistant surgeon) is used. In all cases, modifier -62 is to be used only by a surgeon, not by a physician assistant (PA), nurse practitioner (NP) or other trained surgical staff person. Although a literal reading of modifier -80 indicates that it is only for use with physicians, some commercial carriers will accept the -80 modifier when a PA, certified surgical assistant (CSA) or NP serves as first assistant in surgery, but Medicare requires the -AS (physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery) modifier in such situations.

It is my understanding, that co-surgery is when two surgeons split one reportable CPT code, says Katie McClure, RHIA, surgical coder for Southeastern Gynecologic Oncology, a six-physician practice in Atlanta. Each surgeon performs his or her part of the procedure as a primary surgeon. This differs from a surgery where one surgeon performs the surgery, and the other is an assistant. McClure says that for her practices specialty, co-surgeries most often occur with 58210 (radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]). A gyn will perform the hysterectomy portion as primary surgeon, and our gyn oncologist specialist will perform the removal of nodes portion as a primary. This scenario differs from a mere primary surgeon, assistant relationship. For this to be billed as 58210-80, the scenario would have been the gyn doing the entire surgery as primary, with our doctor only serving in an assistant capacity, she explains.

McClure has run into problems billing for co-surgeons. My experience has been that many people have a misunderstanding of when to use the co-surgeons concept when coding and billing. This is especially a problem if the second surgeon is from a different practice, and his or her office refuses to correctly code the surgery as a co-surgery. This is a problem because, using the example of 58210, one practice wanted to incorrectly code their portion separately as 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) and for our office to code our portion as 38770 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]), says McClure. Under that coding scenario, both surgeons would be guilty of unbundling 58210, which is the one code that describes both procedures.

When Its Not Co-surgery

A scenario that would involve two surgeons is when a gynecologic oncologist performs a radical total hysterectomy and an obstetrician performs a c-section. The question is how to code the surgery if the oncologist opened and closed the incision and spent the majority of time on the case.

Because no single code describes this procedural combination, the surgeons cannot bill as co-surgeons. Each surgeon should report the procedure he or she performed, in this case 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care), assuming there was a global care package, and 59525-22 (subtotal or total hysterectomy after cesarean delivery [list separately in addition to code for primary procedure]; unusual procedural services) to indicate a radical hysterectomy was performed. A claim should be submitted for each physician. Both physicians should submit documentation with the claim to explain the extraordinary circumstances.

Many carriers are unlikely to reimburse for two surgeons for procedures that are not deemed complex enough. Christopher M. Lynch, MD, member of a three-physician group practice in Kansas City, Kan., often works with a co-surgeon to perform a TAH/BSO (total abdominal hysterectomy with bilateral salpingo-oophorectomy) 58150 58550 (laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube[s], with or without removal of ovary[s]). We routinely help each other in this fashion, each performing our own side of the case. We have been documenting and dictating our own reports to describe the amount of the case we performed, but still have some uncertainty as to how to code for it, says Lynch.

Medicare has a list of codes that it deems acceptable to report as co-surgery. (For ob/gyn surgeries, these codes are listed in ACOGs Ob/Gyn Coding Manual: Components of Correct Procedural Coding. This can be ordered at www.acog.org). Both codes used by Lynch are considered by Medicare for co-surgery, but only if extra documentation is provided to prove the medical necessity of using a co-surgeon. In other words, extenuating, complicating circumstances must be present for Medicare to accept co-surgeons with these codes, and most commercial carriers will follow Medicares lead. Although Lynch and his co-surgeon may be able to justify occasional use of co-surgeons, coding every one of these procedures as co-surgeries is likely to prompt rejections across the board. Medicare also stipulates that the two physicians must be of different specialties. Some commercial payers will let the surgeons be of the same specialty, but the bottom-line question is: Was it medically necessary for two physicians to each perform a distinct part of the TAH/BSO, or was one physician acting as an assistant surgeon?

More Billing Strategies for Co-surgeons

When Medicare and most other payers receive a claim with a -62 modifier, they have a formula for determining reimbursement. They take the fee for the procedural code, multiply it by 1.25 and divide this amount between the two surgeons. So essentially, each surgeon receives 62.5 percent of the amount they would have gotten as the primary surgeon. Although this is a reduction, it is higher than if the surgeons simply had to split the surgery cost. The following steps should be taken to ensure optimum reimbursement for co-surgeries:

1. Both physicians should write their own operative notes and identify each other as co-surgeons. It is incumbent upon the physician to write as detailed an operative note as possible. A detailed note will give the carrier a more complete picture of how much work was involved and the time frame in which the work was done, thus proving the need for co-surgeons.

2. Both physicians should use the same ICD-9 codes so that the diagnoses agree. For the procedural codes to be linked appropriately to the diagnostic codes for a co-surgery, both surgeons and/or their staff should confirm with each other which codes are to be used. Although doctors performing different parts of a surgery may link the diagnostic codes to different procedure codes for parts of the surgery not done as co-surgeons, they should list all relevant ICD-9 codes.

3. Both co-surgeons should submit their own HCFA 1500 forms and provide their own documentation. Co-surgeons of the same specialty need to be especially diligent in detailing not only the work that they performed, but that of the other surgeon as well. Send a hard copy of the operative report along with a letter of explanation detailing the need for the co-surgery.

I believe that the best way to handle the situation is to contact the [payers] office beforehand about the co-surgery situation, perhaps during scheduling of the procedure and coordination of the surgery, says McClure. Ultimately, billing for co-surgeons will depend on the understanding between the two physicians about who is going to do (and did) what in the operating room, and how they code the surgery. Surgical coders should work closely with their practices surgeons and the staff of the other surgeon to develop a coding game plan for obtaining the maximum ethical reimbursement to which both are entitled, and one that reflects each surgeons unique contribution to the co-surgery.