Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

MA PPO Host - Claim Payment Policy Bulletin

Title:

Modifier 66: Surgical Team

Policy #:

MA00.014j

Policy

This policy applies to professional providers billing professional or outpatient facility claims, for members enrolled in all Company products.

Modifier 66 is used to indicate circumstances when the complexity of a procedure renders it medically necessary that a "surgical team" is required to successfully complete the procedure. The Company applies the following team surgery indicators from the Medicare Physician Fee Schedule Database (MPFSDB) 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 and considered not medically necessary by the Company.

1 =	Procedure codes that carry a 1 indicator are subject to medical necessity documentation review. This review establishes the medical necessity for team surgery services. 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. The concept of team surgery does not apply to procedure codes with this indicator. Procedure codes with an Indicator 9 should not be reported with modifier 66.

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 '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. Claims submitted with Modifier 66 are subject to pre- and post-payment review and potential denials or retractions for inappropriate use.

BILLING REQUIREMENTS

The Company has established the following requirements for reporting Modifier 66:

A single Team Surgery Review Form must be signed by all members of the surgical team. This document establishes the surgical team's agreed upon percentage of the applicable fee schedule allowed amount for potential reimbursement to each surgeon who is a member of the surgical team.
- The surgical team is responsible for determining the contribution of each surgeon and reporting the contribution as a percentage of work done on a Team Surgery Review Form.
- The percentage total paid to all members of the surgical team should equal but NOT exceed 100 percent.
- All instructions included on the Team Surgery Review Form must be followed.
The procedure(s) performed by the surgical team must be reported by each team surgeon using the same procedure code(s) appended with Modifier 66.
Each team surgeon must act as a primary surgeon during the performance of a surgical procedure that is reported with Modifier 66.
The Company requires that the documentation supports the medical necessity of the procedure requiring a surgical team.
- This documentation should be in addition to the submitted Team Surgery Review Form.
- When the surgical team consists of providers from the same specialty the documentation should support the medical necessity of each provider.
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.
- Professional providers assisting during procedures should not report Modifier 66. Modifier 66 applies only to primary surgeons.

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, team surgery is covered under the medical benefits of the Company's products.

This policy is consistent with Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.

BILLING GUIDELINES

When it is medically necessary for more than two surgeons to carry out a procedure the reported procedure code(s) should be appended with modifier 66 indicating the surgical team approach. If the procedure requires two surgeons refer to the policy regarding Modifier 62: Two Surgeons.

Multiple procedures reported by each team surgeon are subject to multiple surgery reduction guidelines.

Global surgical rules apply to each surgical service reported by each surgeon participating in the team surgery.

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, specialized equipment, and typically consists of surgeons from different specialties. Each surgeon performing a unique function and utilizing special skills integral to the total procedure can be considered a member of the surgical team.

For each procedure performed by the surgical team, each surgeon should report the procedure code(s) appended with modifier 66. Documentation (medical report, operative report, etc) should be submitted by each surgeon in addition to the Team Surgical Report Form.

As used in this policy, surgical team and team surgery are used interchangeably.

References

American Medical Association [AMA]. Coding with Modifiers. 4th ed. United States of American. AMA; 2011.

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.

Optum 360. Understanding Modifiers. West Valley City, UT. Optum 360; 2018.

Coding

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes and and Healthcare Common Procedure Coding System (HCPCS) 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)

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

66 Surgical Team

Coding and Billing Requirements

Cross Reference

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

Policy History

Revisions From MA00.014j:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024

Revisions From MA00.014i:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
07/01/2023	This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2023

Revisions From MA00.014h:

03/22/2023

This policy has been reissued in accordance with the Company's annual review process.

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2022.

Revisions From MA00.014g:

6/07/2021

This version of the policy will become effective 06/07/2021. The intent of the policy remains unchanged, but the policy has been updated to clarify current benefit application.

Coding Attachment B: Eligible Indicators 1 and 2 Procedure codes has been removed from this policy. A link to the Medicare Physician Fee Schedule Database has been added to the coding table.

Modifier 66 has been added to the policy under the Miscellaneous Coding Information heading of the coding table

Revisions From MA00.014f:

01/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

Revisions From MA00.014e:

07/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2020.

The following ICD-10 CM codes been added to this policy: 50949, 66987, 66988

Revisions From MA00.014d:

12/16/2019

This version of the policy will become effective 12/16/2019. The policy has been issued to communicate the Company’s continuing position on Modifier 66: Surgical Teams. The references were updated accordingly.

The following criteria have been added to this policy:

Professional providers assisting during procedures should not report Modifier 66. Modifier 66 applies only to primary surgeons.

Version Effective Date: