General Surgery Coding Alert

Successful claims require modifier -62 and physician-to-physician cooperation

When reporting co-surgeries, you should make sure  the procedures qualify for co-surgery by appending the appropriate modifier and by supplying adequate documentation to support all claims.

First Step: Check the Physician Fee Schedule

Before filing a co-surgery claim, you should check with the Physician Fee Schedule database to be sure the procedure you wish to report qualifies for use with modifier -62 (Two surgeons). If modifier -62 doesn't apply to a particular code, two surgeons cannot claim themselves as co-surgeons for that procedure.

Don't waste your effort: "Medicare won't pay for co-surgeries with all codes or will only pay for co-surgeries with a given code under certain circumstances," says Stephanie Collins, CPC, healthcare consultant with Gates, Moore & Company in Atlanta. "To avoid mistakes that will lead to a rejected claim, you should know up-front whether and when modifier -62 applies to the code(s) you wish to report."

When determining if modifier -62 applies, CMS divides all CPT codes into four categories. To find the status of a given code, look to column "V" -- labeled "CO-SURG" -- of the fee schedule database.

If you find a "1" in column V: You may append modifier -62, but you must supply documentation to establish medical necessity for two surgeons. Specifically, your documentation must show which special circumstances or skills required two surgeons to share responsibility. For example, the extraordinary duration of a trauma surgery may require that two surgeons work in shifts, allowing each to scrub out while the other continues the procedure. Or the surgeons may work simultaneously but perform distinct components of a procedure.

If you find a "2" in column V: You may append modifier -62 as long as each of the operating surgeons is of a different specialty. This can also occur during trauma surgery, because a patient may require several simultaneous procedures requiring the skill of different surgeons.

If you find a "0" in column V: Medicare will not allow modifier -62 for that procedure, and you may not bill for co-surgeons.

If you find a "9" in column V: The concept of co-surgery does not apply. You should not report modifier -62 for these procedures.

Note: You may download the Physician Fee Schedule database from the CMS Web site (www.cms.gov). Use the "search" function to locate "2004 Physician Fee Schedule."

Second Step: Append Modifier -62

You've checked the fee schedule database. Now be sure to append modifier -62 to the appropriate code(s).

Remember: You should only apply modifier -62 for procedures in which the operating surgeons worked as co-surgeons, Collins says. To qualify as co-surgeons, the operating surgeons must share responsibility for the surgical procedure, with each serving as a primary surgeon during some portion of the procedure, according to section 15044 of the Medicare Carriers Manual (MCM).

Coding example: A general surgeon and neurosurgeon work as co-surgeons during vertebral corpectomy (63090, Vertebral corpectomy [vertebral body resection], partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root[s], lower thoracic, lumbar, or sacral; single segment).

After the general surgeon accesses the site, the neurosurgeon performs the vertebrectomy and arthrodesis (22558 and 22585). The general surgeon assists in placing instrumentation (22845, Anterior instrumentation; two to three vertebral segments) to stabilize the spine, and the neurosurgeon finishes by placing a bone graft (20931) for additional spinal support.

In this case, both the general surgeon and neuro-surgeon would report 63090-62 for the corpectomy, but only the neurosurgeon would report the fusion and bone grafts (22558, 22585 and 20931) because the general surgeon did not serve as a co- or assistant surgeon during those procedures. The neurosurgeon will also bill for the instrumentation (22845) and, because he assisted in the procedure, the general surgeon may also report 22845 with modifier -80 (Assistant surgeon) appended (see "Here's How To Avoid the Modifier -62/Modifier -90 Mix-Up" for more information on modifier -80).

Third Step: Coordinate Your Claim

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, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J.

The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the standard fee. For example, in the above scenario of the general surgeon and neurosurgeon working together during a corpectomy (63090), each surgeon would receive about $374, based on national average payments ($598 for the standard fee x 1.25 = $747.50. Each surgeon receives half of this, or $373.75).

If one of the two co-surgeons files incorrectly, however, either surgeon could face a total loss of payment. To ensure your documentation measures up, follow these four simple rules:

1. Each physician should document his own operative notes. Because co-surgeons each perform a distinct part of the procedure, they can't "share" the same documentation, Cobuzzi says. Each physician should provide a note detailing what portion of the procedure he performed, how much work was involved and how long the procedure took.

2. Each physician should identify the other as a co-surgeon. And, both surgeons must submit claims for the same procedure with modifier -62 appended.

3. The co-surgeons should link the same diagnosis  to the common procedure code. Before submitting a claim with modifier -62, coders from each practice should confirm that both claims have the same ICD-9 code(s).

4. Each physician should submit his own claim with his own documentation. Because claims for co-surgeons of the same specialty can come under scrutiny, each physician should diligently note both the work he performed and the work the other physician performed, Cobuzzi says. Many physicians even submit a letter to the carrier detailing the reason for two surgeons, which can help with claims success.