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Team Surgery Review Form
Modifier 66: Surgical Team
TEAM SURGERY REVIEW FORM
The attached document is the Company's Team Surgery Review Form. This form must be completed, signed, and dated by each team surgeon and submitted to the Company. Each provider must specify the percentage of the total work they performed during the team surgery. This percentage establishes the percentage of each provider's fee schedule allowance as reimbursement for that provider's participation in the team surgery.
Team Surgery Review Form should be submitted to the Company. This single form
include all required information.
Submission of required information does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, and applicable provider contracts and policies apply.
To access and view the Team Surgery Review Form:
Select the Adobe
PDF icon below.
Attachment Action. The attached document is formatted as read only.
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