Otolaryngology Coding Alert

Fail to report the same CPT®, modifier for both surgeons, and you waste $2K.

Don't mess up your multi-provider coding by assigning the wrong modifier(s). Modifiers can be a friend or a foe, depending on how you use them -- or when you use them.

Scenario: The otolaryngologist performs the approach for an orthopedist who does a spinal osteotomy with neck exploration. The case of two surgeons calls for the use of a modifier, but which one?

The main key in a multi-provider scenario is to treat each physician's work as a separate activity. However, deciding when to report a case as co-surgery, assistant surgery -- or something else -- has more to it than meets the eye. Find out with these frequently asked questions.

1. What Distinct Roles Do Modifiers 62, 80, 81, 82 Play?

You know that a modifier is at hand in this case, but more importantly you should be able to tell what role each modifier plays in order for your procedure codes to blend well together. Here are the most common modifiers used in multi-provider situations:

• Modifier 62 (Two surgeons). Append this to each surgeon's procedure when the physicians perform distinct, separate portions of the same procedure (a single CPT® code). Also referred to as co-surgery, modifier 62 applies when the skill of two surgeons (usually of different skills) is required in the management of a specific surgical procedure.
• Choose between modifier 80 (Assistant surgeon), modifier 81 (Minimum assistant surgeon), and modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) when one surgeon assists the other with multiple portions of the case rather than completing his work independently. What to look for? Make sure your physician indicates in his documentation that he's working with an assistant surgeon, what the assistant surgeon did, and why he or she was used during the case.
• Attach modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) when you report a nonphysician practitioner's (NPP's) involvement to Medicare.

Warning: Not all payers recognize modifier AS. You should verify the correct way to report the NPP's service before completing your claim.

2. Can Modifier 51 Do The Job Of Describing Multi-Provider Procedures?

It's easy to fall into the lure of using modifier 51 (Multiple procedures) when you're coding for multiple procedures during the same operative session, but you could end up in the gutters if you're not careful enough.

Why: Modifier 51 tells the payer that a surgeon was present and performed multiple procedures during a single operative session. If a surgeon is not physically present and did not actually perform all of the multiple procedures in a surgical case, it's not appropriate to indicate that he was by using modifier 51.

3. How Will Two Comparable Claims Help Your Billing?

In the given scenario, both the otolaryngologist and the orthopedist each should report 22220 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical), and append modifier 62 to the procedure. An orthopedist may call in a specialist to handle the approach -- in this case, the otolaryngologist -- usually if the patient has an altered surgical field due to excessive scarring as a result of prior surgery.

When co-surgery is performed, each surgeon will dictate separate operative reports, which state that the physician was a co-surgeon (not an assistant) for the procedure.

When a surgery is coded and billed as a Co-Surgery, each co-surgeon is paid 62.5 percent of the fee for the CPT® code billed, (22220-62 in this case). In order to receive the 62.5 percent, each co-surgeon must bill the co-surgery at 125 percent and the payer will pay them 50 percent of their billed fee. If the co-surgeons bill the surgery out at 100percent, the co-surgeon will only receive 50 percent because he did not increase the fee to 125 percent.

Catch: You don't use modifier 62 if the physicians are not reporting the same CPT® code. If each doctor can represent his work with a separate CPT® code, skip modifier 62. If both surgeons failed to send a claim with the same code and modifier declared (22220-62), you could end up throwing away a total of about $2,001.63 in reimbursements (125 percent of 47.13 RVUs for nonfacility, multiplied by 2011 conversion factor of 33.9764). That is $1,000.82 for each surgeon.