modifier 62


Hayden, ID
Best answers
Hello ,

I have a case where the co surgeon feels that he should get credit for all cpt codes even though he clearly states in his documentation that he only performed the exposure. Will someone pls review and give their expert opinion? Dr. D , the co surgeon is not mentioned in any other part of the operative report.

I have added coded the case like this -

22552 *2-62
prime surgeon's report-
After thorough
discussion of the risks and benefits, he elected to proceed with surgery. Due to his neck
habitus, as well as his prior cervical fusion at the C6-C7 level, I asked Dr. Tom deTar to
assist with the neck exposure as the C3-C4 levels down to the C7 level would be necessary to
be exposed for this operation. Dr. deTar after evaluating the patient agreed to proceed
with exposure assistance.
The incision line was infiltrated with local anesthetic and then Dr. DeTar began
the operation. Details of his exposure will be detailed in a separately dictated operative
report. However, once exposure to the anterior spine was completed, he then turned the
operation over to myself and we proceeded.

Co surgeon's report-

INDICATIONS FOR OPERATION: The patient had a prior history of cervical fusion and was
recommended to have revision surgery by Dr. Raber. I was asked to assist due to the fact
that he had scar tissue and prior cervical spine surgery. Preoperative evaluation of his
larynx showed normal vocal cord function. He did report a mild sense of dysphagia prior to
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room, was placed
supine on the operating table. He was induced with general anesthesia and a monitoring
endotracheal tube was passed without difficulty and breath sounds were present bilaterally.
The monitoring endotracheal tube was attached to the nerve monitor. Stimulating ground
electrodes were placed in the left shoulder. The shoulder roll was placed. The head was
placed in the midline and the scar was marked with a marking pen and the scar was injected
with 1% lidocaine with 1:100,000 epinephrine. The shoulders were taped inferiorly. The
patient was then prepped and draped in the standard sterile fashion. I began with an
incision through the previous scar and carried it slightly medially to allow a better
exposure to both the superior and inferior limits of the dissection. Subplatysmal skin
flaps were elevated superiorly and inferiorly with electrocautery. Dissection was then
carried out along the anterior border of the sternocleidomastoid muscle. Bleeding from the
anterior jugular vein was controlled with suture ligature. The carotid sheath was then
identified. The vagus nerve, jugular vein and carotid artery were all identified.
Dissection was then carried out along the medial border of the carotid artery and followed
superiorly. Some brisk bleeding was encountered in the scar tissue in the area of the
superior thyroid vein and artery. This was eventually ligated with suture. The superior
laryngeal nerve was positively identified and could be stimulated and was preserved.
Dissection was carried down medial to the carotid down to the spine. The esophagus was
identified and dissected off of the spine and, once the spine was completely dissected free
from the overlying soft tissue, the vagus nerve was stimulated and there was noted to be
normal stimulation of the recurrent nerve. At this point, I turned the operation over to
Dr. Raber, who proceeded with the removal of spinal hardware and fusion and closure.