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Ophthalmology and Optometry Coding Alert

Reader Questions:

Check Both Surgeons' Notes on Modifier 62 Claims

Published on Sat Jun 24, 2006

Question: Our ophthalmologist recently performed a pars plana lensectomy and posterior vitrectomy with the help of another surgeon. I am trying to file the claim with modifier 62 (Two surgeons), but I have never used the modifier before, so I am a little wary. What should I keep in mind when filing a claim with modifier 62?

Michigan Subscriber

Answer: The first thing you should do is report 66852 (Removal of lens material; pars plana approach, with or without vitrectomy) for the pars plana lensectomy and vitrectomy. Then ask yourself:
 

  •  Does each surgeon have his own notes? When acting as co-surgeons, two physicians cannot share the same documentation. Have each physician provide a note describing what portion of the procedure he performed, how much work was involved, and how long the procedure took.

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  •  Does each surgeon note the co-surgeon in his documentation? Make sure that both of the doctors involved in the co-surgery identify the other as a co-surgeon. In order for your modifier 62 claim to succeed, both physicians must submit claims for the same procedure, and both physicians must use modifier 62.

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  •  Are each surgeon's diagnosis codes and procedure codes identical? Co-surgeons need to report the same diagnosis codes and CPT codes. You can make sure the codes line up by having someone check both claims before sending them out to the payer.

    • If you can answer "yes" to all of these questions, you've got an acceptable claim; attach modifier 62 to 66852 to show that it took two surgeons to perform the procedure. For Medicare, payment will be made only when the claim is submitted with documentation.
     
    You may submit the claim and wait for the request for documentation, or drop to a paper claim and submit with the appropriate documentation attached to support the need for two surgeons performing separate parts of one billable procedure.
     
    If approved by Medicare, the allowed amount will be 125 percent of the normal payment and paid at 62.5 percent to each surgeon.

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