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Use modifier 62 for surgeon duos using same code, but make sure you can justify it

Question: When two surgeons are working a patient, when is modifier 62 (Two surgeons) appropriate and when is modifier 80 (Assistant surgeon) appropriate?

Answer: If you’re going to bill 62, the procedure must “really need the individual skills of two surgeons to even perform — a complex nature, like certain spine or heart transplant procedures,” says Corina Marquardt, CPC, CPMA, senior consultant with the Haugen Consulting Group in Denver.

CMS helps you figure out whether these modifiers are appropriate by listing co-surgery and assistant-at-surgery status indicators in the relative value file of the Medicare physician fee schedule. For modifier 62, 0 means no payment, 1 means payment with “supporting documen- tation” for the medical necessity of the four-hander and 2 means payment with no extra documentation needed; for modifier 80, 1 means no payment, 0 means payment with supporting documentation and 2 means payment with no extra documentation needed.

Note: For some CPT codes associated with transcath- eter aortic valve replacement (TAVR) — 3336133365 and 0318T — CMS requires the 62 modifier and that the procedure be performed by an interventional cardiolo- gist and a cardiothoracic surgeon.

Nonetheless, says Marquardt, make sure you note the necessity of the second surgeon in case you get challenged. For “two surgeons” billing for Medicare, each surgeon must have a different specialty, but both surgeons must bill the same CPT code. “Each surgeon must perform an individual, intricate portion of the surgery,” Marquardt says. Take 63090 (Vertebral corpectomy [vertebral body resec- tion], partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment). A co-surgeon would be justified if the corpec- tomy has several segments, says Marquardt; for example, the operation may require a thoracic surgeon to perform the opening, gain access and approach, while an ortho- pedic surgeon might perform the corpectomy, interbody fusion and instrumentation.

Another example would be 61580 (Craniofacial approach to anterior cranial fossa; extradural, includ- ing lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration), in which a thoracic surgeon would provide similar services for a neurosurgeon, says Valerie Fernandez, MBA, CCS, CPC, CIC, CPMA, manager of coding client program develop- ment for H.I.M. ON CALL Inc. in Allentown, Pa.

But supposing the thoracic surgeon were also asked to perform another procedure on the patient that has its own code — for example, secondary repair of dura for a cere- brospinal fluid leak (61618)? Then she would bill the code with 80 as the assistant surgeon. Thus she could have both 80 and 62 lines on the claim.

For 61580-62, each surgeon would also do his or her own operative note, says Fernandez. For 61618-80, “the assistant merely needs to be documented in the primary surgical op note,” says Marquardt; the assistant doesn’t need to do a note. However, the primary surgeon must indicate the services the assistant surgeon provided in documentation, she adds.

The difference in compensation between the two modi- fiers is large. While surgeons each get 62.5% of their rate on 62, the assistant only gets 16% for 80; if a physician assis- tant, nurse practitioner or certified nurse specialist assists at surgery, the AS modifier is used, and their compensa- tion is 13.6% (85% of 16%). — Roy Edroso (