Clean claim submission is the ultimate trick to ensure rightful and timely reimbursements from insurance payers. However, healthcare is often tailored to the unique requirements of each patient. As a result, CPT codes sometimes fail to provide the specificity needed for accurate reimbursements. That’s where modifiers come in. They supply additional information to explain the exact nature and complexity of the care service.
There are numerous modifiers in medical billing that practitioners can use as per the need. In this guide, we will discuss modifier 62, its description, applications, and how it differs from modifier 80.
So, let’s dive right into the details.
Modifier 62 – Description
Modifier 62 indicates that two surgeons of different specialties (co-surgeons) performed a patient’s surgery together as primary surgeons, each handling a distinct part of the procedure. Such a procedure is known as co-surgery.
However, modifier 62 documentation requirements mandate that the information provided in the claim must justify the medical necessity of two practitioners operating on the same patient simultaneously, as specified by the Medicare Physician Fee Schedule Database (MPFSDB).
The following indicators define the Centers for Medicare and Medicaid Services (CMS’s) rules regarding co-surgery:
- Indicator 0 – Co-surgeons are not allowed and will not be paid.
- Indicator 1 – Co-surgeons may receive payments, but with relevant supporting documentation establishing the medical necessity of co-surgery.
- Indicator 2 – Co-surgeons are allowed and will be paid. However, no documentation is needed if the requirements for a dual specialty procedure are met.
- Indicator 9 – The concept does not apply
The Correct Way to Use Modifier 62
- Both providers must agree to append the modifier to the claim.
- The two co-surgeons will receive reimbursement at 62.5% for each co-surgeon, but the indicator in MPFSDB should be either 1 or 2.
- The diagnosis and procedural codes should be the same in both claims.
- Both practitioners should provide operative notes for the part they performed.
- The billed amount can be different.
Mistakes to Avoid While Appending Modifier 62
- Avoid applying the modifier 62 if the second surgeon is an assistant.
- If only one healthcare provider appends this modifier, the reporting physician will receive reimbursement at a 100% rate, and the other claim will trigger a denial.
- If both surgeons submit a claim without this modifier, it will result in incorrect payment.
Scenarios Where Modifier 62 is Applicable
Here are some real-world scenarios for a better understanding of the modifier 62 and its correct application:
Scenario # 1 – Co-Surgey
When two surgeons with distinct roles collaboratively perform a single procedure, each will bill the procedure with Modifier 62.
Example Procedure – Coronary Artery Bypass Grafting
A cardiothoracic surgeon performs cardiopulmonary bypass, sternotomy, and harvesting of the saphenous vein. Contrarily, a cardiovascular surgeon is required to perform coronary artery anastomoses.
Scenario # 2 – Complex Surgical Procedure
Another scenario requiring modifier 62 is when the surgical procedure is so complex that it needs two surgeons from different specialties to perform a specific part.
Example Procedure – Esophagectomy with Gastric Pull-Through for Esophageal Cancer
A thoracic surgeon performs the mediastinal dissection after resecting the diseased esophagus. On the other hand, a gastrointestinal surgeon mobilizes the stomach to perform anastomosis and gastric pull-through.
Example Procedure – Pelvic Exenteration
A general surgeon and gynecologist will perform this procedure. The general surgeon performs a colostomy and removes the bladder and a portion of the colon, while the gynecologist completes the remaining surgical procedure.
Modifier 62 vs 80
In this section, we will explore the differences between two common modifiers; 80 and 62. However, before we dive into the details, here’s a table giving you quick insight into the specifics:
| Questions to Ask? | Modifier 80 | Modifier 62 |
|---|---|---|
| What is the role of the second surgeon in the procedure? | Assistant Surgeon | Primary Surgeon |
| What should be the medical billing procedure? | The lead surgeon will bill for the entire procedure while the assistant surgeon will only bill for their services. | Both co-surgeons will bill for the whole procedure. |
| What will be the reimbursement rate? | The lead surgeon will receive 100% payment. Contrarily, the assistant will get only a percentage of the primary surgeon’s fee (typically 16%). | Both co-surgeons will get 62.5% for the procedure. |
When deciding between modifiers 80 and 62, the most important question is, does the provider serve as an assistant or a primary surgeon? If the answer is affirmative for the latter, you should use modifier 62, else modifier 80 should be used.
In cases where each healthcare practitioner acts as a primary surgeon, the reimbursement will be split between both surgeons. That is, each surgeon will receive 62.5% for the performed surgical procedure, meaning that the CMS will reimburse 125%.
On the other hand, when the claim contains modifier 80, the assistant surgeon gets only a percentage of the lead surgeon’s total fee. For example, if the primary surgeon gets 100%, the other provider will receive 16% for the rendered services.
However, note that the specific policies and guidelines related to the use of these modifiers may vary based on the procedure and the insurance payer’s policy. Thus, we recommend inquiring about the payer’s specific reimbursement rules. It will help you ensure coding accuracy and clean claim submission, leading to faster reimbursements.
Summary
Here is a quick summary of what we discussed in this guide! Providers should use modifiers to provide additional information about a procedure to ensure accurate claim specificity.
Thus, if a surgery requires co-surgeons, both practitioners must append the modifier 62 to bill for the whole procedure. In contrast, healthcare providers should use modifier 80 if the second healthcare provider acted as an assistant.
If the claim contains modifier 62, both co-surgeons will receive reimbursement at 62.5%, i.e., the CMS will pay 125% for the rendered procedure. However, you should follow some rules. For example, both providers must agree to append the modifier, use the same diagnosis and procedure codes, and provide documentation justifying the medical necessity of the procedure.
