Otolaryngology Coding Alert

Be sure to match both surgeons’ codes.

Otolaryngologists sometimes perform surgeries with other specialists, such as when they’re asked to take a biopsy, remove a tumor, or resect a portion of the pituitary gland. But does that mean you automatically append modifier 62 (Two surgeons) to your claim? The answer depends on each surgeon’s role during the encounter, the specific procedures performed – and how they document the service.

Pay Attention to Indicators

Check your Medicare physician fee schedule database to confirm that the procedure you wish to report qualifies for modifier 62. Otherwise, your surgeons cannot code and bill as co-surgeons for that procedure. To be eligible for payment, make sure that your procedure codes have either a Medicare co-surgery indicator of “1” or “2.” Remember their meanings:

• If you find a code carries a co-surgery indicator of "1," you must supply documentation to establish medical necessity for two surgeons. Present which circumstances in the procedure requires special skills or expertise by two surgeons sharing a responsibility.
• A "2" in the co-surgery column indicator means that you may append modifier 62 as long as each of the operating surgeons is of a different specialty.

The AMA has a distinct descriptor of the modifier, stating that "each surgeon should report his/her distinct operative work by adding the modifier 62 to the single definitive procedure code." In short, modifier 62 applies for only one primary procedure and its related add-on codes for each surgeon.

Medicare will not allow modifier 62 for a procedure with a "0" indicator, which means that you are not allowed to bill for co-surgeons. The same holds true for procedures with “9” in the co-surgery column. Medicare will not consider modifier 62 for these codes, so don’t even attempt to append it.

Example: Code 31239 (Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy) contains a “0” in the cosurgery column. Thus, you will never be able to report modifier 62 with this code should an otolaryngologist and ophthalmologist perform the procedure together.

Get Matching Surgical Documentation

Co-surgeries billed with modifier 62 usually pay at 125 percent of the rate in the physician fee schedule, which is then split in two by the payer so that each provider receives 62.5 percent of the total fee.

To bill this service as co-surgeons, the physicians must dictate separate operative reports describing their specific roles. Each op note is different and the addition of the two operative notes’ contents add up to equal the description of completing the co-surgery. Neither operative note alone describes the service and CPT® code. And both practices should communicate to make sure each surgeon uses the same CPT® code and the 62 modifier. The same diagnosis code(s) would also have to be used, and the documentation of both surgeons must state that they were co-surgeons for the procedure.

Know When 62 Does Not Apply

When a patient’s condition requires the talents of two different surgical specialties, but each surgeon performs entirely separate procedures, you do not need to include a modifier such as 62. That’s because even if the task performed by the otolaryngologist is similar to that performed by the other surgeon, each physician submits the distinct code that describes what he or she did. There is no penalty or reduction in the value for a surgery if one surgeon opens and the other closes or vice versa. CMS considers this trivial and does not require the use of the 52 modifier when the surgeon did not perform both the open and closure.

Note: The CMS fee schedule does not allow the co-surgeon modifier with many procedures. Private payers who do not follow CMS’s fee schedule may not publish their own lists of procedures that do or do not permit co-surgery. Because of this, always check with the payer prior to the surgery or be prepared to appeal.