MA PPO

Modifier 66: Surgical Team
MA00.014e


Policy

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.

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 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 and considered not medically necessary for team surgery services. 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 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:
  • One 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 Evidence of Coverage, repeat procedures or services by the same professional provider is covered under the medical benefits of the Company's Medicare Advantage 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 and 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)
SEE ATTACHMENT B

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

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

HCPCS Level II Code Number(s)
SEE ATTACHMENT B

Revenue Code Number(s)


Modifiers


Coding and Billing Requirements



Policy History

7/1/2020
7/7/2020
MA00.014
Claim Payment Policy Bulletin
Medicare Advantage
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Yes