How Does Modifier 62 Affect Reimbursement?

Modifier 62 will be added to claims for procedures designated as “co-surgeon allowed” when a claim for the same procedure code with it has been previously submitted and processed for a different provider. Claims for more than one surgeon should have each surgeon’s provider identification number.

The following Situations are Considered Co-Surgery:

  • Two surgeons of different specialties work together to perform a specific procedure with a single procedure code.
  • Two surgeons of the same or different specialties simultaneously perform parts of the procedure (e.g., heart transplant).
  • Two surgeons simultaneously perform the same or similar procedure(s) on bilateral body parts, which shortens the total anesthesia time required for one surgeon to perform the same set of bilateral procedures consecutively (e.g., bilateral knee replacements).

The following Situation is not Considered Co-Surgery:

  • One or more surgeons of different specialties each perform different, specific CPT codes which are not billed by the other surgeon, even if performed through the same incision.
  • In this situation, each surgeon may be reimbursed for a primary procedure and multiple surgery discounts only apply to the procedures billed by each surgeon.

Codes Eligible for Co-Surgeon Modifier 62

For claims processed on or after July 1, 2018 (regardless of the date of service):

  • Procedure codes with a co-surgeon indicator of “0” on the Medicare Physician Fee Schedule (MPFSDB) are not eligible to be performed as co-surgery and will be denied if submitted with it appended.
  • Procedure codes with a co-surgeon indicator of “1” on the MPFSDB require submission of supporting documentation for review to establish the medical necessity of two surgeons for the procedure.
  • Procedure codes with a co-surgeon indicator of “2” on the MPFSDB are considered eligible for it (co-surgery) if the two surgeons are of different specialties.
    • Two surgeons of the same specialty may also be appropriate in some instances, e.g. heart transplant or bilateral knee replacements.
    • 33361-33369 cardiac transthoracic aortic valve replacement (TAVR) and implantation (TAVI).
      • CPT guidelines for procedure codes 33361-33369 state that TAVR/TAVI procedures require two physicians; all components must be reported with it.
      • Procedure codes 33361-33369 will be denied if submitted without it appended.
    • Procedure codes with a co-surgeon indicator of “9” on the MPFSDB are not eligible for it; the co-surgeon concept does not apply. These procedure codes will be denied if submitted with it appended.

Billing and Coding Requirements for Modifier 62

For the procedures performed as co-surgery, both co-surgeons are expected to bill the exact same combination of procedure codes with modifier 62 appended. Additional procedures performed in the same operative session may be reported as primary surgeon or assistant surgeon.

Billing discrepancies

Any discrepancy in procedure codes reported with it between the two cosurgeon’s claims causes both claims to require additional investigation and delay of processing.

Example # 1:

Surgeon A:

  • 22554-62 (anterior cervical fusion)
  • 22585-62 (additional level)

Surgeon B:

  • 22600-62 (posterior cervical fusion)
  • 22614-62 (additional level)

If a claim is received with a modifier appended after another claim for that procedure has been processed and released as the primary surgeon, the subsequent claim with it appended is denied.

  • If one surgeon reports as the primary surgeon and a second surgeon reports as a cosurgeon for the same procedure codes and neither claim has been released, both claims will be pended and a non-clean-claim review is triggered. Review of medical records (operative report(s)) may be required. Corrected claim(s) will be required so that both surgeon’s claims agree about whether or not co-surgery modifier 62 applies.

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Resources:

BCBS Corporate Reimbursement Policy