Medical Billing and Coding Healthcare Blog

As part of "Road to 10," the online resource built by the Centers for Medicare & Medicaid Services (CMS) with input from providers, CMS has published a series of ICD-10 interactive case studies.

In each case study, users are presented with a sample medical case and asked several questions about how to properly document and code that case in ICD-10.

After completing the questions, users are presented with their results with comparison to peers, as well as a sample way to code the case in ICD-9 and ICD-10.

To date, CMS has released the following case studies:

Looking for more free ICD-10 resources? PGM Billing, a leading provider of physician practice and ambulatory surgery center billing and revenue cycle management services, recently launched a comprehensive "ICD-10 Code Lookup Tool" that allows users to easily convert ICD-9 to ICD-10 codes and vice versa. Bookmark it so you can easily access the conversion engine for practice leading up to the Oct. 1, 2015 transition date and use once the transition from ICD-9 to ICD-10 is made.

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).

Medical coding and billing is complex. It requires a high level of experience and knowledge for appropriate coding, modifier application and payor-specific medical billing procedures.Outsourcing medical billing to an outside professional medical service provider is growing in popularity as it is often the most cost-effective and highest income generating choice for facilities. When claim submission and payment collection is in the hands of a well-qualified vendor, organizations have more time and resources to focus on patient care and business growth.

Contact PGM Billing, a leading provider of practice and ASC billing and coding services, to learn why outsourcing may be the right choice for your facility.

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