Use Correct Surgery Modifiers in Medicare Claims

Medicare auditors working under the Recovery Audit program have identified significant payment errors related to surgery. Be sure to bill correctly for the following, using the right modifiers.

(Note: Novitas Solutions' website has undergone major revision. You may need to navigate to the Modifiers page by choosing Jurisdiction H>Claims>Modifiers. Novitas will present a free webinar to introduce you to the new site on Nov. 20, 1-2:30 pm CT. It will cover how to find local coverage determinations, coding guidelines, bulletins, reference materials, and more. You can register now.)

Co-Surgery

When two or more surgeons with different specialties contribute to and submit claims for the same operative session for the same patient and same date of service, all must use a co-surgeon modifier.

• Modifier 62 (two surgeons) — If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Fee Schedule Data Base (MFSDB). See  How to Use the Searchable Medicare Physician Fee Schedule (MPFS) (PDF) from the Centers for Medicare & Medicaid Services (CMS).
      When billed correctly, Medicare pays each co-surgeon 62.5 percent of the global surgery fee schedule amount.
       Example: A surgeon bills for CPT code 61548, Hypophysectomy or excision of pituitary tumor, and bills with modifier 62, for a patient on date of service March 8, 2012. A different surgeon bills for the same service (same CPT code) for the same patient on the same date because he or she was the co-surgeon, yet did not bill with the modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.       
• Modifier 66 (more than two surgeons) — If a team of surgeons (more than two surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier 66. Field 25 of the MFSDB identifies certain services submitted with a 66 modifier that must be documented sufficiently to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow for payment "by report."  No modifier — If surgeons of different specialties each perform a different procedure (with different CPT codes), neither co-surgery nor multiple surgeon rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services.

 See CMS' MLN Matters No. SE1322 (PDF). 

Global Surgical Package (GSP)

Surgeons should be careful how they bill evaluation and management (E&M) services they provide the day before major surgery, the day of minor surgery, 0-10 days after minor surgery, and up to 90 days after major surgery.

Under the Medicare fee schedule, most surgical procedures include pre- and post-operative E&M services. Physicians can indicate that E&M services rendered during the global period are not included in the GSP by submitting with the E&M service:

• Modifier 24 (unrelated E&M service by same physician during postoperative period),
• Modifier 25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service), or
• Modifier 57 (decision for surgery made within global surgical period).

In addition, surgeons can use modifier 79 (unrelated procedure or service by the same physician during the post-operative period) when billing for services they provide to a patient during the post-operative period that were unrelated to the original surgical procedure and not included in the payment for the surgical procedure.

For more information, see:

• CMS' Global Surgery Fact Sheet (PDF),
• Payment guidelines for E&M services provided during the global period of surgery are in the Medicare Claims Processing Manual, Chapter 12, Section 40 (PDF),
• Novitas' Medicare A/B Reference Manual: Chapter 22 Global Surgery and Related Issues (you may need to navigate by choosing Jurisdiction H>Reference Manual), and
• CMS' MLN Matters No. SE1323 (PDF).

 TMA Can Help  

• TMA's popular annual Medicare update seminar is touring the state through Dec. 4. Led by TMA staff experts, this new seminar will help you take Medicare head on in 2014 as it guides you through appeals, audits, common errors, participation options, incentives, documentation, the new Novitas website, and much more. Register today.
• Learn how to conduct a self-audit, what to do with your findings, and how to obtain buy-in for corrective actions in TMA's on-demand webinar, Avoiding RAC Audits.
• Contact TMA Practice Consulting at (800) 523-8776 to schedule a Coding and Documentation Review. 

Published Nov. 13, 2013  

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