modifier 62

Modifier 62 (2022) Description, Uses, Guidelines & Examples

Modifier 62 appends with services when “Two” surgeons perform the surgical procedures. Read on for a full description, billing guidelines and more.

Summary

Modifier 62 uses to bill for the services of two surgeons when performing the same procedure on the same day on an identical patient during the same encounter.

It may require two different skills from different specialties to perform the service due to the complex nature of the patient’s condition and the nature of the procedure. The other possibility is the patient’s condition, and the additional physician is not working as an assistant in surgery.

If two surgeons perform the procedure, both must add modifier 62 on both claims. The following are the Co-surgery Pricing Adjustments when CPT code bills with modifier 62 for commercial and Mediad claims: 

The insurance may pay 60% of the total amount according to the physician fee schedule rate.

The insurance or third party only applies co-surgery pricing adjustment when CPT codes bills with modifier 62. It may not use additional procedure codes as primary or assistant surgeon without 62.

The other pricing adjustments may apply before the final allowable amount for each line item is identified, in addition to Co-surgery Pricing Adjustments. Multiple surgery adjustments, assistant surgeon adjustments, and bilateral adjustments pertain to global adjustments.

If insurance pertains to Medicare Advantage claims, they will pay 60% of the total amount according to the fee schedule rate to the contracted providers.

If insurance pertains to Medicare Advantage claims, they will pay 62.5%of the total amount according to the fee schedule rate to the out-of-network providers.

Only one surgeon considers the primary surgeon during the surgery except for the co-surgery or team surgery. 

62 modifier

Modifier 62 Description

Modifier 62 appends with services when “Two” surgeons perform the surgical procedures.

What Is Modifier 62?

Modifier 62 applies to the service when the individual skills of Two surgeons are mandatory to accomplish surgery on the same patient during the same session.

When To Use Modifier 62

The following are the uses of modifier 62:

It applies to the surgical procedure when two surgeons operate in the same session on the same patient.

Both surgeons must agree to proceed claim with modifier 62.

The diagnosis code must be the same on both claims.

The payment indicator must be 1 or 2 on the claim for reimbursement.

The insurance will reimburse the payment at 62.5% of MPFSDB.

The bill amount may vary on the claim for both surgeons.  

Modifier 62 must append on both claims. Otherwise, insurance reimburses 100% of the claim with 62 and denies the other.

CPT code must be the same for both claims. 

Modifier 62 Guidelines

Co-surgery, also called surgical procedures, requires two surgeons to operate different anatomical sites simultaneously (e.g., a heart transplant or bilateral knee replacements). Documentation must support the service’s medical necessity and appropriateness of the procedure codes with modifier 62.

If surgical procedure code bills with the payment indicator “0”, it may not be eligible under the physician fee schedule for co-surgery and denied by the insurance or third party payer. 

If surgical procedure code bills with the payment indicator “1”, it may require a manual review by the insurance and documentation that supports the medical necessity of the service and modifier 62.

If surgical procedure code bills with the payment indicator “2”, it may not require any manual review by the insurance and payment rule apply to these services.

If surgical procedure code bills with the payment indicator “9”, it is inappropriate to bill these services with 62. It may deny by the insurance or third-party payors.

Co-surgery or multiple surgery rules do not apply to these services if two surgeons perform different procedures from different specialties. However, if only one physician has various services in the same session, then the numerous surgery rules may apply.

Therefore, it is inappropriate to bill these services with modifier 62, including both physicians using the same incision site. 

Modifier 62 is effective for the claims on or after July 1, 2018. It does not allow to bill service without 62 after this date. It can also apply to claims before July 1, 2018, when they agree to bill roles, codes, and modifiers.

In exceptional circumstances, Modifier 62 applies to two surgeons with the same specialties, such as bilateral knee replacements or heart transplants.

Suppose the surgeons perform CPT codes ranging from 33361-33369 implantation (TAVI) and cardiac transthoracic aortic valve replacement (TAVR). In that case, They must require two physicians to perform these procedures and require modifier 62 for reimbursement. It may deny by the insurance without 62. 

If there are any Billing discrepancies on the claims with modifier 62 regarding two surgeons, additional reviews may require verifying the documents and lead to a delay in the payments. 

The co-surgeons or co-surgery performed by the physicians require the same CPT and diagnosis codes on the claim. The additional procedure can also report by an assistant surgeon or primary surgeon in the same session. 

If more than two surgeons from different specialties perform the surgery, it is inappropriate to report this service with modifier 62. Instead, this surgery will refer to Team surgery and require modifier 66 on the claim. 

62 and AS or 80 are inappropriate to bill on the same claim line. These claims must report with the appropriate modifier on separate claim lines. The insurance may deny the claim as unprocessable.

Modifier 62 bill with each additional level CPT codes such as 22554-62 (anterior cervical fusion) and 22585-62 (other levels). Similarly, Co surgeon may report for each subsequent service. 

Modifier 62 Examples 

The following are examples of modifier 62 bills with services:

The following are examples of when 62 appends with the CPT codes:

Example 1

A 39-year-old male with multiple fractures in the head region had a severe motor vehicle accident and is now present in the emergency department with constant bleeding in the head region. 

The patient denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms. 

The physician asks for a CT scan of the head region and laboratory studies to confirm the patient’s condition. Then, the physician decides to do a surgical to reshape bone flaps and replace various bone plates in a cosmetically pleasing fashion that allows optimal brain decompression.

Surgeon 2 requires the service related to blood because this procedure has a high risk of a significant blood vessel complication.

Suppose the NPP or Physician performs the assistant service for reshaping bone flaps and replacing various bone plates in conjunction with co-surgeons. They can bill their services with a modifier AS or 80 instead of 62. 

Example 2

A 76-year-old male presents to the office for stage IV liver carcinoma. The patient denies current antibiotic use, near-syncope or syncope, trauma, fever, chills, back pain, abdominal pain, nausea, recent travel, heavy palpitations, dizziness, cough, a recent illness, known sick contacts, changes in stool color, urinary complaints, or any other symptoms.

A patient has had severe body aches and temperature since last week. The patient took some medication for pain, but it is getting worse daily. 

The physician schedules a liver transplant with one surgeon. The co-surgeon requires who has extensive surgical history and microsurgical components, including the bile ducts. The physician orders CT scans of the abdomen region to identify liver is metastasized or not.

Surgeon 2 will perform half of the vascular anastomoses and the microsurgical arterial and biliary anastomoses.

Modifier 62 appends on the services of both physicians. They must agree on the documentation of both procedures for a liver transplant by one surgeon. The second surgeon performs the vascular anastomoses and the microsurgical arterial and biliary anastomoses. 

If these service bills are without 62, the surgeon-1 may pay 100% of the entire procedure, and the insurance will deny others. 

Suppose the NPP or Physician performs the assistant service for liver transplant and anastomoses in conjunction with co-surgeons. It is appropriate to report these services with modifier AS or 80 instead of modifier 62. 

Example 3 

A 76-year-old male presents for surgery related to liver and endocrine glands. The physician consulted with the gastroenterologist. He suggested one surgeon who has experience in the endocrine specialty in addition to the experienced hepatic surgeon for safe mobilization of the left lobe of the liver and resection of the right adrenal pheochromocytoma.

The co-surgeon requires the operation for the extensive adhesions of the pheochromocytoma. It will allow safe mobilization of the right lobe of the liver and resection of the right adrenal pheochromocytoma. The co-surgeon has experience in the retroperitoneum and the vena cava.

The involvement of a co-surgeon requires. The surgeon knows pheochromocytoma and has extensive surgical and intraoperative management experience.

Modifier 62 is appropriate to bill the extensive adhesions of the pheochromocytoma for surgeon A. Surgeon B bills his services with modifier 62 for mobilization of the right lobe of the liver. 

Suppose the NPP or Physician performs the assistant service in combination with co-surgeons. These service bills with modifier AS or 80 instead of modifier 62. 

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