Orthopedic Coding Alert

Coding for co-surgery is often as tricky as the complex procedure that triggers it. For example, suppose your orthopedist performs a complete anterior discectomy and lumbar interbody fusion of L5-S1, along with anterior instrumentation and iliac crest bone grafting. A general surgeon from another practice performs the anterior approach and closes.

You might rationalize that the reimbursement shouldnt be equally shared because the general surgeon only gained access and closed, rather than performing the spinal procedure. Beware: That reasoning could result in overpayment to the orthopedists practice; thus, putting you at risk for fraud and abuse.

So how do you code for the highest reimbursement your practice is entitled to, yet remain ethical? The key to coding accurately for co-surgery is in determining the precise role of each surgeon and then appending the appropriate modifier to the correct procedure code.
Here are two typical scenarios for the type of services rendered during a complex orthopedic procedure involving more than one surgeon. Both have issues that relate to reimbursement.

1. The general surgeon gains access, leaves the operating suite, and returns only for closure. The remainder of the procedures (after the primary one) would be performed with another physician (other than the general surgeon), usually from the orthopedic practice, serving as an assistant surgeon.

In this example, the primary orthopedic surgeon and the general surgeon would each need to submit the primary procedure code with a -62 modifier (two surgeons).
Modifier -62 indicates to the payer that, in this circumstance, the expertise of two primary surgeons were needed to manage the procedure. Hence, the two surgeons must share the code as equals, not as primary surgeon and assistant.

Note: The 1999 CPT manual clarified modifier -62 as follows:

-62 may be appended by surgeons of the same or differing specialty,

-62 should be appended to a single definitive primary procedure, and

-62 should not be appended to add-on codes.

For the remaining procedures, the orthopedic surgeon would submit the codes for what he did. The assistant orthopedic surgeon would submit those same codes with modifier -80 (assistant surgeon), which indicates he or she not only served as an assistant to the primary surgeon but was also present for the entire operation or a substantial part of it. Modifier -80 is always attached to the same surgical procedure as that of the primary surgeon.

Note: The primary surgeon should never attach modifier -80 (assistant surgeon) to his or her claim.

Other than gaining access and closing, the second orthopedic surgeon did contribute and assist on all other major portions of the surgery; therefore, he or she should be reimbursed for that assistance.

2. The general surgeon gains access and remains as an assistant surgeon for the other procedures being performed, then closes the patient. According to CPT 1999, the -62 modifier would be appended to the primary procedure for both surgeons. Then, the orthopedist would list the remaining procedure codes without the -62 modifier. The general surgeon would list the same remaining procedure codes with modifier -80 to indicate that he served as assistant surgeon during those procedures.

As always, check with individual carriers to verify their specific interpretations and requirements.

In general, reimbursement for co-surgery modifiers is as follows:

-62 modifier. Medicare multiplies the base allowable for the procedure by 125 percent and then divides it equally between the participating surgeonsin this case, the orthopedist and general surgeon. Each receives 62.5 percent of the allowable for that procedure.

However, some insurance carriers will recognize a predetermined contract between the physicians that would designate the payment to be divided in a different percentage formula. So, check with your carriers in advance to determine their requirements to see if they will allow for a disbursement that reflects the respective work of each surgeon.

-80 modifier. Generally, payers reimburse assistant surgeons at 16 to 20 percent of the allowable
for the procedure.

Specific Documentation is Vital

In order to append a modifier - 62, both the general surgeon and the orthopedic surgeon must dictate separate operative reports. Each report should specifically address the following questions:

Who performed the anterior approach and closure?

Who performed the primary procedure?

Who assisted with what portion of each procedure?

The primary orthopedist should make sure his or her operative report clearly defines the role of the general surgeon and assisting surgeon.

Finally, some carriers are demanding that all line items on
the claim form must match exactly when billing co-surgery. For example, when both are performing a lumbar arthrodesis, the orthopedic surgeon and the general surgeon must both code 22558-62 with the same diagnosis and same charge, or you may experience denials.

Teaching Hospital Exception

If youre a coder in a teaching hospital, the modifiers will be different, notes Christine Banks, RRA, CPC, a coding specialist for orthopedics at Massachusetts General Hospital.

Most of the time the orthopedists use residents for an assistant surgeon. But, if another orthopedist is used, I have to append modifier -82 [assistant surgeons when qualified resident surgeon not available], rather than -80, she says.

Note: There are strict requirements for the use of modifier -82, such as affidavits swearing no resident was available. Only certain reasons are accepted, so check with your payers for restrictions.

Editors Note: The sources for this article include: Susan Stradley, CPC, CCS-P, senior consultant for Elliott, Davis and Co., LLP, headquartered in Greenville, SC; Jeri L. Harris, CPC, CPC-H, a second-term national advisory board member for the American Academy of Professional Coders; Renee Praul, BA, ART, CPC, coding quality assistance and training, Ministry Health Care, Milwaukee, WI; CPT Companion; American Academy of Thoracic Surgery; CPT Assistant, November 98, page 40; 1998 and 1999 CPT Manual.

Coding for the Assistant Surgeon If an orthopedist is needed to help another surgeon perform a difficult operation, the CPT provides modifier -80 (assistant surgeon) or -82 (assistant surgeon [when qualified resident surgeon not available]). Modifier -80 is for assistant surgical services provided in settings where surgical residents arent used. Modifier -82 is to be used in settings where surgical residents are used, but no qualified resident was available for the case. In reporting these cases, the primary surgeon simply codes the procedures and bills his or her full fee. He or she does not use the modifier and is not financially penalized for using an assistant. According to Barbara Cobuzzi, MBA, CPC, a physician reimbursement specialist and president of Cash Flow Solutions, Inc., in Lakewood, NJ, the primary surgeon should make sure the operative report clearly indicates why an assistant was needed. The assistant may need ammunition for getting paid, she says. Prior to the surgery, the assistant should make sure that the specific case allows for an assistant. Medicare lists specific procedures that will not pay for an assistant, and many private payers use this list or one they have developed. Orthopedic practices should check with their specific payers to find out what these codes are. If the procedure allows an assistant, the assistant will code the procedure appended with the appropriate -80 or -82 modifier. According to Cobuzzi, there is disagreement within the coding community on whether the assistant should bill his or her full fee for assisting. Historically, Medicare has paid only 16 percent of whatever is paid to the primary surgeon, but other payers may pay more. Some practices are afraid if they bill too low, they might have missed an opportunity to be paid more for the assist, says Cobuzzi. In my opinion, I think that billing your full fee suggests that you did the full service, which is not the case. So I recommend that surgical assists be billed at 35 percent of your normal fee. But this is just my opinion and a matter of debate among coding consultants, she adds. It is not necessary for surgical assistants to send in an operative report, but Cobuzzi recommends they check and see how the primary surgeon is billing for the service, and insure that the primary surgeons operative report mentions that an assistant was used and why.