Medicare Advantage Preferred Provider Organization (MA PPO)

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

Modifier 62 is used to indicate instances when two surgeons work together as primary surgeons and perform distinct parts of a procedure. The Company applies the following Medicare Physician Fee Schedule Database (MPFSDB) co-surgery indicators to procedure codes to determine the eligibility for reimbursement consideration. Additionally, the Company may consider procedure codes that carry a co-surgery indicator of​ 9 as eligible for reimbursement consideration when appropriate, e.g., services represented by Healthcare Procedure Coding System (HCPCS)​ S-codes that require the use of two surgeons. ​​​​

0 = Procedure codes that carry an indicator of 0 are not eligible for reimbursement consideration for co-surgery services. The Centers for Medicare & Medicaid Services (CMS) has determined that these services never warrant two surge​ons. 

• Claims received for reimbursement for co-surgery services (two surgeons) represented by procedure codes with an indicator of 0 will be denied as not eligible for reimbursement consideration for co-surgery services by the Company. 

1 = Procedure codes that carry an indicator of 1 are subject to medical necessity documentation review for co-surgery 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 an indicator of 2 are eligible for reimbursement consideration for co-surgery services.​

9 = Procedure codes that carry an indicator of 9 are not eligible for reimbursement consideration for co-surgery services. The concept of co-surgery does not apply to procedure codes with this indicator. Procedure codes with an indicator of 9 should not be reported with Modifier 62.

When co-surgery 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 pre-payment reviews and post-payment 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 the appropriate reporting of Modifier 62: 

• The procedure(s) performed by the co-surgeons must be reported by each surgeon using the same procedure code(s) appended with Modifier 62. 
• The co-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 co-surgery 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 is reported.
• No more than two surgeons may act as a primary surgeon per procedure code reported with Modifier 62. 
• Co-surgeons are usually of different specialties. However, when the co-surgeons 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.
• Neither co-surgeon may act as an assistant surgeon during the same operative session. 
  
• The Company requires that documentation be available supporting the medical necessity (e.g., complexity of the surgical procedure[s], the individual's condition) of co-surgery. The operative report must be made available to the Company upon request.