Medical Billing and Coding Healthcare Blog

The Centers for Medicare and Medicaid Services (CMS) recently released a Medicare Learning Network podcast intended to clarify CMS's existing policy regarding payments errors because of a failure to apply properly the co-surgeon modifier -62, when two or more surgeons of different specialties participate in one operative session and each separately submit claims to Medicare.

CMS noted that when two or more surgeons with different specialties submit claims for the same operative session for the same beneficiary and same date of service, you must use the co-surgeon modifier.

CMS then discussed what happens when two different providers bill the same CPT code, same patient and same date of service and one of the providers bills with modifier -62. In these instances, the other provider must also bill with modifier -62. However, when the co-surgeons are of different specialties and are working at the same time, only modifier -62 may be used.

CMS continued by discussing the Medicare Claims Processing Manual, and what guidance is provided in Section 40.8, “Claims for Co-Surgeons and Team Surgeons.” Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure and/or the patient’s condition. In these cases, if you are an additional physician, you are not acting as assistant-at-surgery.

If two surgeons, each in a different specialty, are required to perform a specific procedure, CMS stated that each surgeon bills for the procedure with a modifier -62, meaning two surgeons. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure at the same time, for example, a heart transplant.

The podcast then discussed billing instructions. CMS provided the following three billing procedures that apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:

  1. 1. Modifier -62: If two surgeons, each in a different specialty, are required to perform a specific procedure, each surgeon bills for the procedure with modifier -62. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure at the same time. Documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Fee Schedule Data Base (MFSDB).
  2. 2. Modifier -66: If you are a team of surgeons, that is, more than two surgeons of different specialties, required to perform a specific procedure, each surgeon bills for the procedure with a modifier -66. To establish that a team was medically necessary, you need to sufficiently document field 25 of the MFSDB, which identifies certain services submitted with a 66 modifier. All claims for team surgeons must contain sufficient information to allow pricing by report.
  3. 3. Different procedures requiring no modifier: If you are surgeons of different specialties and are each performing a different procedure, with different CPT codes, neither co-surgery nor multiple surgeon rules apply, even if the procedures you perform are through the same incision. If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services.

In terms of payments, CMS noted that for co-surgeons (modifier -62), the fee schedule amount related to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier -66) is paid for on a “by report” basis.

CMS concluded with a discussion of two case examples from the recovery auditor review. The first example was a provider bills for CPT code 61548, excision of a pituitary tumor, and bills with modifier -62, for a patient on date of service March 8, 2012. A different provider bills for the same service for the same patient on the same date of service because they were the co-surgeon. However, the co-surgeon did not bill with modifier -62. The second surgeon was overpaid for failing to properly apply modifier -62.

In the second example, a provider bills for CPT code 49652, Laparoscopy, surgical repair, ventral, umbilical, spigelian or epigastric hernia, and bills with modifier -62, for a patient on July 2, 2011. A different provider bills for the same service for the same patient on the same date of service because they were the co-surgeon. However, the co-surgeon did not bill with modifier -62. The second surgeon was overpaid for failing to properly apply modifier -62.

In both of these examples, CMS stated you should add the appropriate modifier to the claim line when you are the co-surgeon, operating on the same beneficiary, on the same date of service.

To download the podcast, click here (zip). To download the MLN Matters article on which the podcast was based (SE1322), click here (pdf).

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The Centers for Medicare and Medicaid Services (CMS) recently released a Medicare Learning Network podcast which was intended to clarify the correct use of certain HCPCS modifiers, specifically when billing for wrong surgery on a patient.

CMS discussed the HCPCS modifier -PC (Wrong Surgery on Patient), which was established in CR6405 (pdf), along with two other modifiers, for use in Medicare billing, to be added, where appropriate, to all claim lines related to surgical error.

CMS noted that providers may be incorrectly using the HCPCS modifier -PC to indicate the professional component for certain services not related to surgical error when the modifier -26 should have been used. CMS stated that providers need to be aware that the use of the -PC modifier on Medicare claims will result in a claim being denied.

CMS noted that modifier -PC is used to identify wrong surgery on a patient. The modifier -PC is to be added, where appropriate, to all claim lines related to a surgical error. Modifier -26, on the other hand, is used to identify the professional component of a service or a procedure.

To download the podcast, click here (zip). To download the MLN Matters article on "Clarification of the Use of Modifiers When Billing 'Wrong Surgery on a Patient,'" click here (pdf).

Struggling with how to properly prepare claims for submission to Medicare, Medicaid and other payers? Seeing an increase in denials? Feel like you are spending too much on billing staff? Consider outsourcing your billing to PGM Billing, a leading provider of physician billing services. Contact PGM today to learn how we can help maximize your reimbursement, reduce your costs and streamline operations.

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