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Know when to use the co-surgeon, assistant-at-surgery, and surgical team modifiers.

Over the last few years, there have been line items on the Office of Inspector General鈥檚 (OIG鈥檚) Work Plan related to co-surgeon and assistant surgeon procedures.

In , the OIG performed a review of 100 sample services and found a 69 percent error rate:

• 49 percent were billed without the correct co-surgery modifier,
• 14 percent without the assistant-at-surgery modifier, and
• 6 percent were identified as duplicate services.

Extrapolated out to the universe of services, the OIG estimates that Medicare improperly paid healthcare providers $4.9 million during calendar years 2017 through 2019. To improve this error rate, let鈥檚 review the guidelines for co-surgery and assistant-at-surgery modifiers.

Assistant-at-Surgery Indicators

There are specific modifiers and documentation requirements when billing for assistant surgeons. Documentation must indicate who the assist was and the role the assist played in surgery.

• When the assist at surgery is a physician, append modifier 80 (Assistant surgeon) to the CPT^庐 code.
• When the assist is a physician鈥檚 assistant, nurse practitioner, or clinical nurse specialist, append modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery).
• When a physician is needed for minimal assistance during surgery, append modifier 81 (Minimum assistant surgeon).
• When a procedure is performed in a teaching facility, residents are typically used as assists. Medicare policy does not permit billing for the assist at surgery as it is part of the resident鈥檚 training. If a qualified resident is not available and a physician assists, append modifier 82 (Assistant surgeon (when qualified resident surgeon not available)) to the assist鈥檚 claim. The documentation must identify why a qualified resident was not available.

To determine if a procedure qualifies for a surgical assist, you will need to check the code鈥檚 indicator. This is found in the Medicare Physician Fee Schedule Database (MPFSDB) in the column labeled ASST SURG:

0 = Payment restriction 鈥� must have supporting documentation.

1 = Assistant at surgery cannot be paid.

2 = Assistant at surgery can be paid.

9 = Concept does not apply.

Co-surgeons Indicators

When two surgeons perform distinct parts of a procedure, both acting as primary surgeons for their part of the service, they will both document an operative note to reflect the services they provided, and both will bill the same CPT^庐 code with modifier 62 (Two surgeons).

To determine if you may use modifier 62, look in the MPFSDB under the CO SURG column:

0 = Co-surgery not payable.

1 = Can be paid with medical necessity established by documentation.

2 = Co-surgeons permitted; no documentation required if two specialty requirements met.

9 = Concept does not apply.

According to the OIG, the needs to be updated to say that the co-surgeon concept applies to bilateral procedures and providers in the same specialty. The policy currently says the co-surgeons concept applies when the providers are 鈥渆ach in a different specialty.鈥�

The OIG also recommends CMS clarify to providers that spinal instrumentation procedure codes must be billed with a co-surgery modifier under Medicare Part B when performed as such.

Team Surgery Indicators

For a highly complex procedure requiring skills of more than two surgeons, each surgeon will submit a claim with modifier 66 (Surgical team). Documentation must establish the medical necessity for each surgeon and the operative note must contain each surgeon鈥檚 role in the surgery.

To determine whether a surgery code allows the use of modifier 66, look in the MPFSDB, in the TEAM SURG column, for the following indicators:

0 = Team surgeons not permitted for this procedure.

1 = Team surgeons could be paid. Supporting documentation is required to establish medical necessity of a team; paid by report.

2 = Team surgeons permitted; pay by report.

9 = Team surgeon concept does not apply.

Once again, CMS states in the Medicare Claims Processing Manual that this concept applies to 鈥渕ore than 2 surgeons of different specialties.鈥� Additionally, modifier 66 only applies when the surgeons are tag-teaming on a single procedure, not when they are each performing different procedures. Likewise, if one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon鈥檚 services.

Indicators Point the Way

It is of utmost importance that, as coders, we are validating payable services in the MPFSDB as well as the National Correct Coding Initiative edits to ensure accuracy in claims reporting. All services being billed with multiple providers should be audited against the MPFSDB to validate the indicator for services rendered.

Melissa Kirshner, MPH, CPC, CPCO, CDEO, CRC, CFPC, CPMA, COBGC, CEMC, 星空入口Approved Instructor,
星空入口Fellow and Angela Clements, CPC, CPMA, CEMC, COSC, CGSC, 星空入口Approved Instructor, CCS.

(A version of this article first appeared on the 星空入口Knowledge Center blog)