Understanding Modifier 62: Co-Surgery Billing

Introduction

Modifier 62 is used in medical billing to indicate that two surgeons were involved in the same surgical procedure on the same patient during the same operative session. This article aims to educate healthcare providers about the appropriate use of modifier 62 and provide valuable information regarding documentation and reimbursement.

When to Use Modifier 62

• Individual skills of two surgeons are required: The complexity of the procedure or the patient’s condition necessitates the expertise of two surgeons with different specialties working independently on distinct parts of the procedure. These surgeons are not acting as assistants.
• Simultaneous performance of different parts: Two surgeons simultaneously perform different parts of the same procedure, like in heart transplants or bilateral knee replacements.

Important Notes

• Always refer to the latest guidelines: While this article summarizes current information, medical billing regulations and codes can change. Refer to official sources like the American Medical Association (AMA) or relevant government agencies for the most up-to-date information.
• Both indicators may require review: The statement about indicator 1 requiring documentation review may be outdated. Currently, both indicators 1 and 2 may trigger review depending on the specific procedure and payer policies.
• Check payer-specific policies: Insurance companies may have different requirements or limitations regarding modifier 62. Always verify with the specific payer before submitting claims.
• Consult a medical billing expert: For complex situations or specific questions about using modifier 62, seek guidance from a qualified medical billing professional.

Appropriate Use

• Two surgeons with different specialties perform a specific procedure for the patient.
• Two surgeons (same or different specialties) simultaneously perform distinct parts of the same procedure.
• Both surgeons bill the same procedure code with modifier 62 appended.
• Reimbursement is typically 125% of the allowed amount, divided equally between the surgeons (62.5% each).
• Multiple surgery guidelines apply if more than one procedure is performed.

Inappropriate Use

• One surgeon acts as an assistant surgeon.
• Both surgeons operate simultaneously but not on the same procedure (rare situations, often in trauma).
• More than two primary surgeons are involved.

Documentation for Modifier 62

• Detailed medical record documentation: This should demonstrate the services provided by each surgeon, indicating their specialties and the specific contributions they made to the co-surgery.
• Reporting indicator: Include the relevant indicator (1 or 2) from the Medicare Physician Fee Schedule (MPFS) Relative Value File (RVF) on the claim form.
• Operative report: Attach a copy of the operative report highlighting the individual roles of each surgeon.

Example 1 of Modifier 62

Two surgeons perform an upper gastrointestinal endoscopy with the placement of a percutaneous gastrostomy tube. One surgeon performs the endoscopy, and the other creates the abdominal incision and inserts the tube. Both surgeons bill CPT code 43246 with modifier 62 and submit copies of the operative report detailing their contributions. Reimbursement is based on 125% of the eligible charge, divided equally between the surgeons.

Example 2 of Modifier 62

A patient undergoes arthrodesis of two thoracic spine interspaces with anterior interbody technique and instrumentation of three vertebral segments. Surgeon A performs the thoracotomy, while Surgeon B handles the arthrodesis and spinal instrumentation. Surgeon A then closes the surgical site. Both surgeons bill the following codes with modifier 62:

• Surgeon A: 22556-62, 22558-62, 22845-62
• Surgeon B: 22556-62, 22558-62, 22845-62

Before claim submission, communication between both surgeons’ offices is crucial to ensure proper claim filing. Modifier 62 usage has specific requirements and potential review triggers. While this article provides general information, always consult official sources and seek professional guidance for accurate and compliant usage.

To conclude,

We hope this article has given you all the necessary information to use modifier 62 appropriately. If you are unsure and need help in medical billing for your practice, you can always contact us. PrimeCare MBS has an experienced billing and coding team that uses exact modifiers to bring accurate insurance reimbursement.

References

• Medicare Physician Fee Schedule (MPFS)
• National Correct Coding Initiative (NCCI)

The American Medical Association (AMA) holds the copyright for the Current Procedural Terminology (CPT®) codes and their associated modifiers, including those mentioned in this article. The use of these codes and modifiers is governed by the AMA’s Current Procedural Terminology (CPT®) Coding Rules and the Healthcare Common Procedure Coding System (HCPCS) guidelines.