Medicare Bundling Cystocele/Rectocele

hstefani

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Recently it was brought to our attention by Medicare that we have been coding Cystocele/Rectocele incorrectly. We are not 100% with Medicare’s decision but are unable to find any thing to the contrary. Here is the scenario:

The OB physician and the Urology physician go in as Co-surgeons. One does the Cystocele, completes the procedure and leaves. The other then begins the Rectocele, completes the procedure and leaves. They are not assisting with each others procedure, they are doing their own separate procedure. Therefore, one provider bills 57240-62 & the other bills 57250-62. However, Medicare says this is unbundling procedure 57260. Is it considered unbundling when it is two different specialties?

The description for 57260 says "combined anteroposterior colporrhaphy" stating the physician does both the cysto & recto but it does not specify two different physicians. I cannot find where it says two different specialties cannot bill each procedure separate. Can any one help me with this?
 
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Anna Weaver

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co surgery

Recently it was brought to our attention by Medicare that we have been coding Cystocele/Rectocele incorrectly. We are not 100% with Medicare's decision but are unable to find any thing to the contrary. Here is the scenario:

The OB physician and the Urology physician go in as Co-surgeons. One does the Cystocele, completes the procedure and leaves. The other then begins the Rectocele, completes the procedure and leaves. They are not assisting with each others procedure, they are doing their own separate procedure. Therefore, one provider bills 57240-62 & the other bills 57250-62. However, Medicare says this is unbundling procedure 57260. Is it considered unbundling when it is two different specialties?

The description for 57260 says "combined anteroposterior colporrhaphy" stating the physician does both the cysto & recto but it does not specify two different physicians. I cannot find where it says two different specialties cannot bill each procedure separate. Can any one help me with this?
Have you tried billing the 57260 for both physicians with a 62 modifier? Or not using the 62 modifier at all?
According to my modifier book Coding with modifiers third edition, page 187;

"If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (heart transplant or bilateral knee replacements). Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (see publication 100-4)
If surgeons of different specialties each perform a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply, even if the procedures are performed through the same incision."


Hope this helps a little.
 

mbort

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since they are both doing to seperate procedures and dictating there own reports for only the procedure they performed, then its my understanding that you would bill only for the procedure that your surgeon performed without the 62 modifier. The 62 modifier would be if they were both helping each other for both of the procedures.
 
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Medicare is right

You wouldn't code the two procedures separately if one surgeon performed them both, so you shouldn't code the two procedures when you have co-surgeons each doing a distinct part. CPT clearly tells us that if two surgeons perform distinct part(s) of the same procedure then you bill the procedure w/ a -62 modifier for each surgeon.

In this case you have code 57260 which combines the two distinct procedures performed by these two specialists. You would not unbundle this code but would bill out 57260-62 for each of the surgeons.

The use of the-62 modifier does still require each surgeon to dictate a separate operative note specifying what portion of the procedure s/he performed.

Another reason you wouldn't code these out as two separate procedures (one for each surgeon) is that you don't have two separate opening and closing of the operative field.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

hstefani

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57260 is where this issue started. They were billing this way to begin with, but were told to start billing their own procedure, not the combined.

Thanks for your help. I need any information I can get at this point.

Have you tried billing the 57260 for both physicians with a 62 modifier? Or not using the 62 modifier at all?
According to my modifier book Coding with modifiers third edition, page 187;

"If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (heart transplant or bilateral knee replacements). Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (see publication 100-4)
If surgeons of different specialties each perform a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply, even if the procedures are performed through the same incision."


Hope this helps a little.
 

hstefani

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Good point about the opening and closing...I think that will help build our case with the providers. There is some resistance from them with this change. Thank you!

You wouldn't code the two procedures separately if one surgeon performed them both, so you shouldn't code the two procedures when you have co-surgeons each doing a distinct part. CPT clearly tells us that if two surgeons perform distinct part(s) of the same procedure then you bill the procedure w/ a -62 modifier for each surgeon.

In this case you have code 57260 which combines the two distinct procedures performed by these two specialists. You would not unbundle this code but would bill out 57260-62 for each of the surgeons.

The use of the-62 modifier does still require each surgeon to dictate a separate operative note specifying what portion of the procedure s/he performed.

Another reason you wouldn't code these out as two separate procedures (one for each surgeon) is that you don't have two separate opening and closing of the operative field.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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