Reimbursements

Category:

Co-Surgeon & Surgical Team

Reimbursement Policy: NDRP-Surg-002
Topic: Surgery
Effective Date: July 1, 2018
Last Reviewed:
October 3, 2019

Description:

This policy provides guidelines for the reimbursement of services provided by a Co-Surgeon and Surgical Team.

 

Definitions:

Modifier Description
62 Co-Surgeon
66 Surgical Team

 

Policy:

Co-Surgeon is defined as two or more surgeons, working together simultaneously as primary surgeons, to perform distinct parts of an operative procedure during the same operative session. When Co-Surgery is performed, each surgeon should report the same procedure code with the modifier 62 appended. Any associated add-on codes that were performed during the same surgical session may also be reported with the modifier 62.

Surgical Team is defined as two or more surgeons with different skills, and generally of different specialties, working together to carry out various procedures of a complicated case. When a surgical team is used for surgery, each surgeon should report the same procedure code with the modifier 66 appended. Any associated add-on codes that were performed during the same surgical session may also be reported with the modifier 66.

Modifier
Reimbursement Percentage
62 62.5% of the fee schedule
66 62.5% of the fee schedule

 

Note: Multiple surgery reductions may apply to Co-Surgeon and Surgical Team claims when one or more physicians are billing multiple surgery codes that are eligible for reductions. Refer to the Multiple Surgeries Reimbursement Policy for additional information.

 

Procedure Codes Eligible for Co-Surgeon Reimbursement:

The Co-Surgeon procedure code eligible list are developed based on the Center for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) Relative Value Unit (RVU) File status indicators. All codes in the PFS RVU File with status indicators “1” or “2” for Co-Surgeon are eligible for reimbursement.

CMS Definition for Co-Surgeon Status Indicators
1 Co-surgeons could be paid. Supporting documentation is required to establish medical necessity of two surgeons for the procedure.
2 Co-surgeons permitted. No documentation is required if two specialty requirements are met.

 

 

Procedure Codes Eligible for Surgical Team Reimbursement:

The Surgical Team procedure code eligible list are developed based on the CMS PFS RVU File status indicators. All codes in the PFS RVU File with status indicators “1” or “2” for Surgical Team are eligible for reimbursement.

CMS Definition for Surgical Team Status Indicators
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.

 

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

 

Cross Reference:

CMS PFS RVU File

 

History:

Date Updates
10/03/19 Added CMS status indicators, Limitations and Exclusions, Disclaimer and History.

 

 


Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.