Question Two Surgeons/Two Surgeries/Same Operative Session

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How do I submit a claim for the following scenario: two ophthalmologists/surgeons who work for the same practice operate on the same patient/same eye at the same operative session. One surgeon does a vitrectomy (67036). The other does a cataract removal (66850).
 

bsegawa

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I am unfamiliar with your coding but modifier policy has a great debate over 51 verses 59 and it would be wise to which payer may prefer. I hope this helps. Medical Coder for 6 years.
Modifier 51 Multiple procedures indicates that the same provider performed multiple procedures—other than E/M services—at the same session. You should list the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and subsequent procedures. Use modifier 51 to indicate:
  • Same procedure, different sites
  • Multiple operation(s), same operative session
  • Procedure performed multiple times
Most payers apply a “multiple procedure discount” with modifier 51. This refers to the practice of reducing the reimbursement for subsequent procedures because of shared resources when two or more procedures are performed together. CPT® Appendix E lists codes that are exempt from modifier 51.

Modifier 59
Modifier 59 Distinct procedural service is used to indicate a:
  • Different session or encounter
  • Different procedure
  • Different site
  • Separate incision, excision, lesion, injury, or body part
Modifier 59 is frequently appended to those codes defined as “separate procedures” in CPT®. Designated separate procedures commonly are carried out as an integral component of a more extensive procedure. Only when a procedure or service designated as a separate procedure is carried out independently, and is considered to be unrelated or distinct, may it be reported separately.
 
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Would this be considered a co-surgeon situation? Each surgeon, although both ophthalmologists, has his own specialty/subspecialty (ie, one is a vitreoretinal specialist/surgeon, the other is a glaucoma specialist/cataract surgeon). Although working together at the same operative session for the same patient/same eye, each did his own distinct procedure. The patient was being treated for a traumatic cataract and vitreous prolapse in the anterior chamber. First, the vitrectomy was performed by one physician, then the other physician attempted to remove the lens. During removal, a portion of the lens fell to the back of the eye. The physician performing the vitrectomy removed these remaining lens fragments, which completed the treatment.
 
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