Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 66: Surgical Team

Policy #:00.10.17h

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 team surgery indicators to procedure codes to determine the eligibility for reimbursement consideration for team surgery services:

0 =
Procedure codes that carry a 0 indicator are not eligible for reimbursement consideration for team surgery services. The Centers for Medicare & Medicaid Services (CMS) has determined that these services never warrant a surgical team.
  • Claims received for reimbursement for surgical team services represented by procedure codes that carry a 0 indicator will be denied by the Company.
1 =
Procedure codes that carry a 1 indicator are subject to medical necessity documentation review. This review establishes the medical necessity of a team of physicians. Additionally, the operative report must be attached to the Team Surgery Review Form.
  • Team Surgery Review Form:
    Prior to claims submission, providers are required to submit the Team Surgery Review Form. This document must be completed, signed, and dated by each surgeon seeking reimbursement as a member of the surgical team. Additionally, the operative report must be attached to the Team Surgery Review Form. Refer to the Cross References section of this policy for a link to the Team Surgery Review Form.
  • Medical Necessity Documentation Requirements:
    The Company will communicate any additional supporting medical necessity documentation requirements.
    Professional providers should not submit medical records to the Company with the claim.
2 =
Procedure codes that carry a 2 indicator are subject to a documentation review to confirm the services performed by the surgical team.
  • Team Surgery Review Form:
    Prior to claims submission, providers are required to submit the Team Surgery Review Form. This document must be completed, signed, and dated by each surgeon seeking reimbursement as a member of the surgical team. Additionally, the operative report must be attached to the Team Surgery Review Form. Refer to the Cross References section of this policy for a link to the Team Surgery Review Form.
  • Medical Necessity Documentation Requirements:
    The Company will communicate any additional supporting medical necessity documentation requirements.
    Professional providers should not submit medical records to the Company with the claim.
9 =
Procedure codes that carry a 9 indicator are not eligible for reimbursement consideration for team surgery services. Procedure codes with an Indicator 9 should not be reported with modifier 66.

REPORTING INFORMATION
  • Multiple procedures reported by each team surgeon are subject to multiple surgery reduction guidelines.
  • Each procedure reported with Modifier 66 (surgical team) by each team surgeon is considered for reimbursement eligibility on its own merit.
  • Global surgical rules apply to each surgical service reported by each surgeon participating in the team surgery.
  • Team surgeons are usually of different specialties. However, when the team surgeons are of the same specialty, the medical record and/or operative report must support the medical necessity of participants in the surgical team who are of the same specialty.
  • 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.

    BILLING REQUIREMENTS

    The Company has established the following requirements for reporting Modifier 66 (surgical team):
    • One Team Surgery Review Form must be signed by all members of the surgical team. This document establishes the agreed percentage of the applicable fee schedule allowed amount for potential reimbursement to each surgeon who is a member of the surgical team.
      • The percentage total paid to all members of the surgical team should equal and must not exceed 100 percent.
      • All instructions included on the Team Surgery Review Form must be followed.
    • The procedure(s) performed as a team surgery must be reported by each team surgeon using the same procedure code(s) appended with Modifier 66 (surgical team).
    • Each team surgeon must act as a primary surgeon during the performance of a surgical procedure that is reported with Modifier 66 (surgical team).
    • Each team surgeon 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 team surgery services provided by these professional providers as eligible for reimbursement consideration, regardless of the procedure code indicator.
    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 Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.

Description

Modifier 66 (surgical team) is reported when a procedure requires the skills of more than two surgeons of different specialties who work together to carry out various portions of a complicated surgical procedure. This complicated procedure may require specially trained personnel and specialized equipment. Each surgeon participating in the team surgery is a member of the surgical team.

As used in this policy, surgical team and team surgery are used interchangeably.
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. [CMS Web site]. 01/26/07. 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 the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the TEAM 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)



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 TEAM 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:

66: Surgical team


Coding and Billing Requirements


Cross References

Attachment A: Modifier 66: Surgical Team
Description: Team Surgery Review Form



Policy History

REVISIONS FROM 00.10.17h:
01/01/2017Revised policy number 00.10.17h was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.
Version Effective Date: 01/01/2018
Version Issued Date: 01/05/2018
Version Reissued Date: N/A

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