Orthopedic Coding Alert

Coding for co-surgery is often as tricky as the complex procedure that triggers it. For example, suppose your orthopedist performs a complete anterior discectomy and lumbar interbody fusion of L5-S1, along with anterior instrumentation and iliac crest bone grafting. A general surgeon from another practice performs the anterior approach and closes.

You might rationalize that the reimbursement shouldnt be equally shared because the general surgeon only gained access and closed, rather than performing the spinal procedure. Beware: That reasoning could result in overpayment to the orthopedists practice; thus, putting you at risk for fraud and abuse.

So how do you code for the highest reimbursement your practice is entitled to, yet remain ethical? The key to coding accurately for co-surgery is in determining the precise role of each surgeon and then appending the appropriate modifier to the correct procedure code.
Here are two typical scenarios for the type of services rendered during a complex orthopedic procedure involving more than one surgeon. Both have issues that relate to reimbursement.

1. The general surgeon gains access, leaves the operating suite, and returns only for closure. The remainder of the procedures (after the primary one) would be performed with another physician (other than the general surgeon), usually from the orthopedic practice, serving as an assistant surgeon.

In this example, the primary orthopedic surgeon and the general surgeon would each need to submit the primary procedure code with a -62 modifier (two surgeons).
Modifier -62 indicates to the payer that, in this circumstance, the expertise of two primary surgeons were needed to manage the procedure. Hence, the two surgeons must share the code as equals, not as primary surgeon and assistant.

Note: The 1999 CPT manual clarified modifier -62 as follows:

-62 may be appended by surgeons of the same or differing specialty,

-62 should be appended to a single definitive primary procedure, and

-62 should not be appended to add-on codes.

For the remaining procedures, the orthopedic surgeon would submit the codes for what he did. The assistant orthopedic surgeon would submit those same codes with modifier -80 (assistant surgeon), which indicates he or she not only served as an assistant to the primary surgeon but was also present for the entire operation or a substantial part of it. Modifier -80 is always attached to the same surgical procedure as that of the primary surgeon.

Note: The primary surgeon should never attach modifier -80 (assistant surgeon) to his or her claim.

Other than gaining access and closing, the second orthopedic surgeon did contribute and assist on all other major portions of the surgery; therefore, he or she should be reimbursed for that assistance.

2. The general surgeon gains access and remains as an assistant surgeon for the [...]