Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 62: Two Surgeons

Policy #:00.10.11k

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The Company applies the following Medicare Physician Fee Schedule database cosurgery indicators to procedure codes to determine the eligibility for reimbursement consideration for cosurgery services (two surgeons):

0 =
Procedure codes that carry a 0 indicator are not eligible for reimbursement consideration for cosurgery services. The Centers for Medicare & Medicaid Services (CMS) has determined that these services never warrant two surgeons.
  • Claims received for reimbursement for cosurgery services (two surgeons) represented by procedure codes with a 0 indicator will be denied by the Company.

1 =

Procedure codes that carry a 1 indicator are subject to medical necessity documentation review for cosurgery services.
  • Upon receipt and processing of claims submitted, the Company will communicate any additional supporting medical necessity documentation requirements. However, providers should not submit medical records to the Company until notified.

2 =

Procedure codes that carry a 2 indicator are eligible for reimbursement consideration for cosurgery services.

9 =

Procedure codes that carry a 9 indicator are not eligible for reimbursement consideration for cosurgery services. The concept of cosurgery does not apply to procedure codes with this indicator. Procedure codes with an Indicator 9 should not be reported with modifier 62.
The Company has established the following requirements for the appropriate reporting of Modifier 62 (two surgeons):
  • Each cosurgeon must report the same procedure code(s) representing the cosurgery, appended with Modifier 62 (two surgeons).
    • When multiple procedures are performed as cosurgeries, each procedure code that represents a cosurgery is appended with Modifier 62 (two surgeons).
  • The cosurgeon must be an eligible professional provider.
    • The Company does not recognize interns, residents, or fellows in graduate medical education (GME) programs as eligible professional providers and, therefore, does not consider cosurgery services provided by these professional providers as eligible for reimbursement consideration, regardless of the procedure code indicator.
  • Each professional provider must act as a primary surgeon during the performance of the surgical procedure for which Modifier 62 (two surgeons) is reported.
  • No more than two surgeons may act as a primary surgeon per procedure code reported with Modifier 62 (two surgeons).
  • Cosurgeons are usually of different specialties. However, when the cosurgeons are of the same specialty, the medical record and/or operative report must support the medical necessity of participants who are of the same specialty.
  • Multiple procedures reported by each cosurgeon are subject to multiple surgery reduction guidelines.
  • Neither cosurgeon may act as an assistant surgeon during the same operative session.
  • Each cosurgeon must be prepared to submit an operative report that documents the medical necessity (e.g., complexity of the surgical procedure[s], the individual's condition) of cosurgery. The operative report must be made available to the Company upon request.
When cosurgery services meet all reimbursement eligibility requirements, such services are reimbursed at 62.5 percent of the applicable fee schedule amount for eligible procedures.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.
Guidelines

This policy is consistent with the reporting requirements established by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS).

Inappropriate billing may result in claim overpayments and subsequent retractions or claim underpayments.

Description

    Modifier 62 (two surgeons) is reported when two surgeons (i.e., cosurgeons) act as primary surgeons during the same operative procedure or session for the same individual. Two primary surgeons may be required because of the complex nature of the procedure(s) and/or the individual’s condition. The cosurgeons are typically of different specialties who perform consecutive or over-lapping parts of the same procedure. An example of another situation where two surgeons may be required is the simultaneous performance of a bilateral procedure (e.g., bilateral lung reduction surgery). Each surgeon submits the same procedure code, representing the entire surgical procedure, appended with Modifier 62 (two surgeons).
    References

    Optum360. 2018 Understanding Modifiers: Softbound.


    American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.

    Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. §40.8. pg. 95-97. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

    Centers for Medicare & Medicare Services (CMS). PFS Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html




    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Medicare's Physician Fee Schedule Search page to perform a search for Current Procedural Terminology (CPT) codes and the corresponding cosurgery indicators; Available at:


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the CO-SURG column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)



Revenue Code Number(s)

N/A


Misc Code

Modifier:

62: Two surgeons


Coding and Billing Requirements


Cross References
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