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Modifier 62: Two Surgeons
MA00.011o

Policy

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 distrinct part(s) 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 for co-surgery services (two surgeons):

 

0 = Procedure codes that carry a 0 indicator 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 surgeons.

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

1 = Procedure codes that carry a 1 indicator 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 a 2 indicator are eligible for reimbursement consideration for co-surgery services.

 

9 = Procedure codes that carry a 9 indicator 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 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.

Guidelines

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


BILLING GUIDELINES

 

When it is medical necessary for for two sur​geons to carry out a procedure the reported procedure code(s) should be appended with Modifier 62. If the procedure requires more than two primary surgeons refer to the policy regarding Modifier 66: Surgical Team.

 

Multiple procedures reported by each co-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 62 is reported when two surgeons 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 co-surgeons 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).


References

American Medical Association (AMA). CPT® 2020 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. Accessed October 13, 2020.

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. Accessed October 13, 2020.


Optum 3602019 Understanding ModifiersWest 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 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)

ICD - 10 Procedure Code Number(s)
N/A

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 and and Healthcare Common Procedure Coding System (HCPCS)​ 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

Modifiers

62 Two surgeons

Coding and Billing Requirements


Policy History

7/1/2023
7/10/2023
MA00.011
Claim Payment Policy Bulletin
Medicare Advantage
No