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two surgeons, different procedures

  1. Cool two surgeons, different procedures
    Medical Coding Books
    I have 2 ophthalmologists from 2 different practices, each having their own subspeciality (glaucoma and retina) that performed surgery at the same session. Each one performed their own surgery, never assisting the other. Retina doctor's claim to Anthem BC paid using 62 modifier. Glaucoma doctor's claims are being denied stating 62 is not appropriate. Any suggestions?

  2. #2
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    Quote Originally Posted by nannewburg View Post
    I have 2 ophthalmologists from 2 different practices, each having their own subspeciality (glaucoma and retina) that performed surgery at the same session. Each one performed their own surgery, never assisting the other. Retina doctor's claim to Anthem BC paid using 62 modifier. Glaucoma doctor's claims are being denied stating 62 is not appropriate. Any suggestions?
    They both have to bill the same CPT(s) for the surgery to use modifier 62. You may want to verify that the other doctor billed correctly...

  3. #3
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    Quote Originally Posted by nannewburg View Post
    I have 2 ophthalmologists from 2 different practices, each having their own subspeciality (glaucoma and retina) that performed surgery at the same session. Each one performed their own surgery, never assisting the other. Retina doctor's claim to Anthem BC paid using 62 modifier. Glaucoma doctor's claims are being denied stating 62 is not appropriate. Any suggestions?
    40.8. Claims for Co-Surgeons and Team Surgeons(Rev. 1, 10-01-03)
    B3-4828, B3-15046
    A. General
    Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery.
    B. Billing Instructions
    The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons:
    • 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, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (See §40.8.C.5.);
    • If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66.” Field 25 of the MFSDB identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”
    • If surgeons of different specialties are each performing 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). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services. (See §40.6 for multiple surgery payment rules.)
    For co-surgeons (modifier 62), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier 66) is paid for on a “By Report” basis.
    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

  4. Default
    Thank you for your help

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