Practice Management Alert

Question: Our physicians often work with other surgeons in the operating room. We seem to get a lot of denials for the procedures, however. I think we're using the wrong modifiers. What modifiers do we need to append to our claims to ensure payment on co-surgeries?

Arkansas Subscriber

Answer: If your physician is acting as a co-surgeon with another physician, you should report the procedure code and append modifier 62 (Two surgeons). For your modifier 62 claim to succeed, both physicians must submit claims for the same procedure, using the same procedure code, and both physicians must use modifier 62. When reporting co-surgeries, you should work closely with the other operating surgeon's staff to ensure that each practice gets its fair share of the reimbursement. Medicare and most other payers reimburse procedures coded with modifier 62 at 125 percent of the regular fee schedule amount. The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the standard fee.

Important: When acting as co-surgeons, two physicians cannot share the same documentation. Have each physician provide a note describing what portion of the procedure he performed, how much work was involved, and how long the procedure took. Make sure that both of the doctors involved in the co-surgery identify the other as a co-surgeon.

Allowed procedures: Also check which procedures accept co-surgery modifiers. The Medicare Physician Fee Schedule indicates for each procedure whether you can the CPT code as a co-surgery. It may also indicate that Medicare allows billing the code as a co-surgery with documentation only. This means that the claim will not get approved just with a CMS 1500 claim but needs the documentation to show why the co-surgeon was needed.

Alternative: If your physician only acts as a "second pair of hands" in the operating room, assisting the primary surgeon, you should append modifier 80 (Assistant surgeon) to the procedure code. An assistant surgeon does not have to provide his own operative notes, but the primary surgeon should note the second physician's name as the assistant surgeon in his operative report.

Warning: If your physician performed side-by-side surgeries with the other surgeon but did not perform cosurgery (modifier 62) or assist with the other surgeon's procedure (modifier 80), do not apply any modifiers.