General Surgery Coding Alert

Question: We had three surgeons working together to perform a delayed left breast reconstruction. The procedure involved deep inferior epigastric perforator free flap (DIEP flap) with microvascular anastomosis.

All surgeons are of the same specialty, working together to complete the procedure during the same operative session. All of them are doing their own operative reports, listing one of the surgeons as staff and the other two as co-surgeons.

What is the correct CPT^® code, and would it be appropriate to bill out a single code for all three surgeons using modifier 66?

Kentucky Subscriber

Answer: The correct code for the procedure is 19364 (Breast reconstruction with free flap). Under no circumstances should you bill this scenario with modifier 66 (Surgical team). Medicare and most other payers don’t recognize this as a procedure that allows team surgeons. Using modifier 66 would result in a needless rejection, and you probably couldn’t win an appeal.

Why three? The question for your physicians is why three surgeons were required to perform a procedure usually performed by one surgeon. Several scenarios could explain the situation and result in different coding:

If one physician was called away or was hurt and couldn’t continue and another surgeon from the same practice stepped in to finish the procedure, you would bill this under a single physician (probably the one who completed most of the surgery). There would be no extra reimbursement under this scenario. Perhaps the third surgeon was assisting or possibly acting as co-surgeon, in which case you would bill accordingly using the appropriate modifier, such as 80 (Assistant surgeon).

If one physician was training another as part of the procedure, or if the two surgeons were performing the surgery in tandem because of a difference in skill level, there would be no additional reimbursement for the "trainee" whose involvement focused on improving his/her knowledge and skills. If the third surgeon was a medically necessary assistant or co-surgeon, this could be billed separately as above.

If there is good documentation that the patient had a very complex reconstruction that required six hands due to multiple procedures, scarring from radiation therapy, exceptional bleeding risk, etc. the only alternative would be to bill co-surgeons (modifier 62, Two surgeons) with an assistant surgeon. This would require excellent documentation and may only get paid on appeal. If all three truly acted as co-surgeons (each taking the leading work on a different part of the procedure) and you have excellent documentation of exceptional complexity, you might also use modifier 22 (Increased procedural service).