Urology Coding Alert

To secure reimbursement for the variety of procedures that call for two surgeons to work on the same patient on the same dayeven at the same timeurologists must use the correct modifiers.

These two-surgeon procedures can include a urologist and a surgeon from a different specialty, two primary urologists, or one primary urologist and one assistant. Each scenario has a unique way to correctly code.

Two Surgeons, One Procedure: Modifier -62

Consider a case in which two surgeons are needed for the operation, and each surgeons specialty, talent or expertise is distinct and essential from the others. A prime example of a two-surgeon procedure involving a urologist is a pelvic exenteration for gynecologic malignancy (58240). In this case, a urologist may need to work with a gynecological oncologist or abdominal surgeon to complete the operation.

Note: This is also a case in which two urology subspecialists may work together on different aspects of the same procedure. For example, a uro-oncologist may perform the actual exenteration, while a uro-plastic surgeon is called in for the reanastomosis.

For this type of surgery, even though each specialist performed a distinct component of the operation, both surgeons distinct talent is needed to complete the procedure. One surgeon is not assisting the other. Therefore, each specialist will report the procedure 58240 (pelvic exenteration for gynecologic malignancy), along with the -62 modifier. The CPT manual explains modifier -62 as follows: When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single definitive procedure code.

The key to getting full reimbursement for the two-surgeon procedure is to provide documentation showing that each surgeons ability and expertise is distinct and medically necessary to complete the surgery. Both surgeons will bill for the procedure, and both must dictate a separate report that describes, in detail, their distinct parts in the operation. In addition, both should document the other surgeons role and mention that the other surgeon also will be dictating a report. Be sure to include the proper diagnosis codefor example, 183.0 (malignant neoplasm of ovary) or 183.2 (malignant neoplasm of fallopian tube).

As a result of the -62 modifier, each physician will receive a reduction in the normal fee schedule. It would be inappropriate to bill for the entire procedure when you didnt perform the entire procedure, says Anne Cunningham, RN, MBA, compliance manager for the Boston Medical Center.

When reimbursing the -62 modifier, Medicare will place the value of the procedure at 125 percent, then divide that equally between the two surgeons. This results in a payment of 62.5 percent for each physician. If one doctor does the majority of the work, this should be noted on each claim sheet and backed up by both operative notes so the payment can be divided accordingly.

Two Surgeons, Two Procedures:
Using Modifier -52

A primary urologist and a surgeon from a different specialty performing distinct operations consecutive to one another also falls under this category. This is a common occurrence because it is much more convenient for patientsrather than having to undergo the trauma of surgery twice, they can get both procedures done in one trip to the OR.

According to JoAnn Rogers, billing manager for Gulf Coast Urology, a three-physician practice in Bradenton, FL, We see this type of scenario a lot. Especially with women who are having a hysterectomy and opt to have a bladder tuck on the same day.

In this case, each specialist bills for his entire procedurethe gynecologist bills for the hysterectomy, 56308 (laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube[s], with or without removal of ovary[s]) and the urologist submits his own reimbursement form for the bladder tuck, 51845 (abdomino-vaginal vesical neck suspension, with or without endoscopic control).

According to CPT guidelines, if a physician performs his own procedure, independent of any other physicians working on the patient that day, he should bill for his procedure separately.

According to George F. Alex, CPC, a medical coding instructor at Johns Hopkins School of Medicine, and managing partner of Iatro, LC, a Baltimore-based coding consulting firm, No modifier is necessary unless one surgeon is not able to perform all the criteria included in the definition of the code he is reporting.

One instance of this is when both surgeons work through the same incision. If the operative CPT code includes opening or closing in the definition, then the surgeon must include the -52 modifier (reduced services) along with his procedural code if he did not perform the opening or closing. In the operative notes, the surgeon should record which part of the CPT procedural definition was omitted so the payer can reimburse accordingly.

In addition, if it has been planned that only one surgeon will provide all of the follow-up care, the surgeon not providing follow-up care should append a -54 modifier to indicate that he has provided only the surgical portion of the procedure.

Surgical Assistants: Modifiers -80 and -82

There are two distinct modifiers to classify the aid of an assistant in two different scenarios: those involved with a private practice and those involved with a teaching facility.

Private practice: In all non-teaching facility procedures, modifier -80 (assistant surgeon) should be used, regardless of the area of specialty for each surgeon or the actual procedure being claimed. For example, if two primary surgeons are working on distinct procedures (such as the hysterectomy and bladder tuck mentioned above), but the urologist assists during the hysterectomy (56308) and the gynecologist assists during the bladder tuck (51845), each surgeon can bill for his own procedure and submit a claim for the second procedure with the -80 modifier appended to the procedure they assisted on. When a surgeon submits for a claim at the assistant level, he or she will receive 16.5 percent of the total payment, according to Medicare.

Teaching facility: It is important to note that modifier -82 (assistant surgeon when qualified resident surgeon not available) is for teaching facilities only. The assistant surgeon submitting an -82 claim must document why he or she assisted with the procedure rather than a resident. This can be done in the operative report with an explanation from the primary surgeon. For example: Due to the complexity of the procedure, I asked Dr. X to assist. I didnt feel it was appropriate to have a resident assist at this level or The urological resident on call was not available at the time of the procedure. Dr. X kindly agreed to assist in his place. The payment structure for the -82 modifier follows the same guidelines as the -80 modifier, paying the assistant 16.5 percent of the total procedure.