Modifier 62: Appropriate Use

October 9, 2020Surgery

Modifier 62: Two Surgeons

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. If the surgery is billed with a modifier 62 and the indicator is 1, the claim will suspend for manual review of any documentation submitted with the claim. If the surgery is billed with a modifier 62 and the indicator is 2, then the payment rule for two surgeons apply.

If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a CPT modifier 62 (Two Surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., a heart transplant or bilateral knee replacements.

When a provider reports an eligible procedure with modifier 62 appended, reimbursement will be 125% of the allowed amount, divided equally between the co-surgeons. Each surgeon will be reimbursed 62.5% of the allowed amount. If there is more than one procedure performed, multiple surgery guidelines apply.

Appropriate Use

• Two surgeons (each in a different specialty) must perform a specific procedure for the patient
• Two surgeons (same or different specialty) are each performing parts of the same procedure simultaneously, such as heart transplants, or bilateral knee replacements
• Both physicians bill the same procedure code appending modifier 62
  • Reimbursement is made at 62.5% of Medicare Physician Fee Schedule database (MPFSDB)
  • Indicator in MPFSDB must be either 1 or 2

Inappropriate Use

• One surgeon is acting as an assistant surgeon
• Rare situations, usually in trauma situations, where both surgeons are acting simultaneously, but not working on the same procedure
• There are more than two primary surgeons

Documentation for Modifier 62

• Medical record documentation should show the services of each provider to support co-surgery
  • Indicating the different specialties
  • Services of each surgeon
• Reporting indicator 1 of the Medicare Physician Fee Schedule (MPFS) Relative Value File (RSF),
  • The second claim will suspend for review
• If the PFS RVF has an co-surgery indicator of “2” and both surgeons have different specialties,
  • Medicare can allow payment without additional documentation

Example of Modifier 62

Example 1

Two surgeons perform an upper gastrointestinal endoscopy with directed placement of a percutaneous gastrostomy tube. One surgeon performs the endoscopy. The other surgeon makes an incision into the abdomen and inserts the gastrostomy tube. The surgery is appropriate for co-surgery.

Both surgeons should bill using the same CPT procedure code (43246) and modifier code 62. Both surgeons should include a copy of the operative report, indicating the portion of the procedure each performed. Plan benefits for the procedure will be paid based on 125 percent of the eligible charge. The surgeons in this example have arrived at a mutually agreeable percentage split of the fee (70/30) and have indicated this split on the claims (block 19).

Example 2

A patient’s surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments. Physician ‘A’ performs a thoracotomy at the start of the surgical session, and Physician ‘B’ performs the arthrodesis and spinal instrumentation. Upon completion of the arthrodesis and spinal instrumentation, Physician ‘A’ closes the operative site.

The physicians would report the codes as follows:

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We hope this article would have given you all the necessary information to use modifier 62 appropriately. If you are still not sure and need help in medical billing for your practice, you can always contact us. E2E Medical Billing Services has an experienced billing and coding team that uses exact modifiers to bring accurate insurance reimbursement. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com