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Co-Surgeon Documentation

  1. #1
    Long Island/New York
    Default Co-Surgeon Documentation
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    I have a documentation question for either a co-surgeon (62) or assistant surgeon(80). My dr (Dr A) performed a spinal fusion. A second Dr (Dr B) performed the approach and later on the closure. This is the documentation in Dr A's note:

    "Dr B provided the approach for us. He performed a T9 thoracoabdominal approach with a rib resection of the ninth rib, and then got us down to the vertebral bodies and took the segmental vessel, and exposed everything for us. He will dictate that separately." My Dr then went on the perform the fusion. Towards the end of the surgery he then documented:

    "Dr B now returned for the closure."

    The surgical codes for Dr A are 22810, 20936, 22224. Since Dr B did the approach and did dictate his own op-report I am leaning towards using 22810-62 which would allow Dr B to bill out his own 22810-62. Am I wrong and since he only did an approach and closure and nothing else have Dr B use 22810-80 for assistant surgeon? Any suggestions or links to sites that better explain which documentation is needed for 80 or 62 modifiers. Thanks.

  2. #2
    Milwaukee WI
    Default Co surgeon
    CPT Appendix A defines the Modifier thus: 62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure ...

    So, yes both Surgeon A (the ortho surgeon) and Surgeon B (the general or CT surgeon who did the open/close) would report 22810 [62].

    (I work for the general surgeons who do this for the ortho surgeons performing anterior approach arthrodesis.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Greater Pittsburgh
    I also have an ortho surgeon that does fusions with a thoracic surgeon for the approach and agree with the 62 modifier on each physicians CPT.
    jdemar, CPC, CMA

  4. #4
    Long Island/New York

  5. Default
    I would like to jump on board this topic and ask a related question. I code for ASC's and have had similar situations where Dr.A will excise a pilonidal cyst then bring in Dr.B to do a flap/adjacent tissue closure. Both dictate seperate notes and mention in the notes that the opposing Dr. did a different procedure and will dictate seperately.

    Since I am doing this for an ASC can I still use -62, it's not on the modifiers approved for hospital outpatient list on the front of the CPT.
    Last edited by Billington; 12-01-2009 at 02:31 PM. Reason: Typo

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