Otolaryngology Coding Alert

Separate documentation is your key to modifier -62 success.

When your otolaryngologist performs surgeries in conjunction with other specialists, such as neurosurgeons and general surgeons, ask yourself three important questions to ensure your physician gets the dollars he deserves.

Question 1: Did Both Surgeons Perform Part of a Single Procedure?

Sometimes the surgeons involved in a case obviously complete separate procedures, but sometimes the distinction isn’t so clear. A good example is when a neurosurgeon asks the ENT to take a biopsy, remove a tumor, or resect a portion of the patient’s pituitary gland.

During the procedure, the otolaryngologist typically takes down the anterior wall of the sphenoid sinus and puts the speculum in place. The neurosurgeon then removes the back and superior walls of the sphenoid sinus to get to the sella turcica. Once the pituitary tumor or biopsy is removed, the otolaryngologist closes up.

You report the procedure with a single code: 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic), whether one or two surgeons are involved.

Question 2: Did the Surgeons Have Relatively Equal Roles?

In the example above, some ENT coders submit incorrect claims with codes such as:

• 30520 – Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
  
• 31050 – Sinusotomy, sphenoid, with or without biopsy
  
• 31287 – Nasal/sinus endoscopy, surgical, with sphenoidotomy.
  

This incorrect choice might be because the ENT might have a lesser role in the procedure than the neurosurgeon or because the approach involves resecting the septum and approaching via the sphenoid sinus. Or, it might be a case of the coder being more familiar with these choices, which all describe a portion of what was done.

Important: Even though the approach may not be quite as much work as the definitive procedure, the CPT® code is shared between the two surgeons because the definitive procedure cannot be completed without the work of the co-surgeon. In order to accomplish the single CPT® code in this example (61548), the skills and work of both the otolaryngologist and neurosurgeon are needed.

Remember that code 61648 includes the approach. Because of this, not reporting the co-surgery or filing one of the incorrect codes listed above would be considered reporting work in excess of what your surgeon performed. That would lead to double billing, compliance problems, and reduced reimbursement for the otolaryngologist. That’s because payers know that 61548 describes the entire procedure, so they might consider submitting an additional code as unbundling.

Question 3: Did You Remember to Include Modifier -62?

To file accurately for the procedure, both surgeons should append modifier -62 (Two surgeons) to the CPT® code on their claims, if the co-surgeon modifier is allowed.

Co-surgeries billed with modifier -62 usually pay at 125 percent of the rate in the physician fee schedule, which is then split in two by the payer. That means each provider receives 62.5 percent of the total fee.

For example, code 61548 is assigned a total of 44.54 RVUs in a facility setting. Once you multiply 44.54 by 1.25 and divide it by 2, it translates to approximately 27.84 RVUs per surgeon.

Billing requirements: To report the procedure as co-surgeons, the otolaryngologist and neurosurgeon must dictate separate operative reports describing their specific roles. The sum of the work and details involved in both operative notes add together to describe 61548.

Communicate with the other surgeon’s office to verify that they included modifier -62 on their claim, and that both physicians state that they were co-surgeons for the procedure. You both also need to report the same diagnosis code(s). You do not have to submit the claims with the same fees. Assuming the neurosurgeon is in a different group from your group, she would submit 125% of her fee and you would submit 125% of your fee.

Caveat: When a patient’s condition requires the talents of two different surgical specialties, but each surgeon performs entirely separate procedures, you don’t need to append a modifier. Even if the task performed by the otolaryngologist is similar to that performed during the pituitary excision (i.e., the approach and/or the reconstruction/graft), each surgeon uses the distinct code that describes what he or she did.

For example, during skull base surgeries, an otolaryngologist may perform the approach, a neurosurgeon perform the definitive procedure, and a reconstructive otolaryngologist perform the closure. The case would involve three surgeons, with each billing one of the three codes it takes to accomplish skull base surgeries.

Final note: The CMS fee schedule doesn’t allow modifier -62 on some procedures. Private payers who do not follow CMS’s fee schedule may (or may not) publish their own lists of procedures that do or do not permit co-surgery. As a result, always check with the payer beforehand so you’ll know what to expect in reimbursement or whether you should be prepared to appeal.