Some procedures are more complex than others and may require the expertise of multiple surgeons. Modifiers help identify such procedures on the medical claim. However, there is not one modifier that fits all surgeon-related situations. As a result, while billing for surgical procedures with several surgeons, many may keep scratching their heads as to which modifier to append.
This guide will discuss all aspects of one such modifier, the modifier 66! From what it entails, the practical scenarios, and billing guidelines to how it is different from another surgical modifier, i.e., 82.
So, without further ado, let’s get started!
Modifier 66 – Description
Modifier 66 indicates to the insurance payer that three or more surgeons of different or the same specialty worked as primary surgeons to perform significant and distinct parts of a procedure.
Modifier 66 – Examples
The following are some practical scenarios where the modifier 66 may apply:
Kidney Transplant
Assume a scenario where a patient suffering from end-stage renal disease, which is secondary to kidney disease, requires a kidney transplant. Thus, a team of surgeons is formed to carry out the job. It comprises a transplant surgeon specializing in ureteral implantation, a transplant surgeon specializing in vascular anastomosis, and a general surgeon specializing in abdominal wall closure.
Each surgeon performed a distinct and critical part in the kidney transplantation and should report the CPT code 50365 with modifier 66.
Lung Transplant
Let’s say a patient with severe pulmonary hypertension, which is secondary to idiopathic pulmonary fibrosis, needs a single lung transplant. Besides, the patient has a history of previous open-heart surgery that has resulted in altered cardiac anatomy and significant adhesions.
Thus, considering the patient’s complex history, a surgeons’ team is formed comprising three cardiothoracic surgeons with different specializations.
As a result, the cardiopulmonary bypass specialist initiates and manages cardiopulmonary bypass, dissection, and adhesion specialist carefully dissects the lungs from the surrounding tissues, and airway and vascular anastomosis specialist performs the delicate anastomoses of the donor’s lungs to the recipient’s pulmonary arteries, veins, and bronchi, ensuring proper function.
Since each surgeon performed a distinct and significant part in the lung transplant procedure, every surgeon is eligible to report the CPT code 32852 with modifier 66.
Heart Transplant
Consider a complex case of heart transplant requiring a team of three cardiothoracic surgeons. The patient was diagnosed with end-stage cardiomyopathy. The complications were due to a rare congenital condition, situs inversus (reversed organs), and complex vascular anomalies involving the great vessels.
The first surgeon who specialized in situs inversus and complex cardiac anatomy was responsible for managing the initial dissection and preparation of the patient’s chest. The second surgeon, with expertise in complex vascular anastomoses, performed the intricate connections of the donor’s heart to the patient’s anomalous vessels. The third surgeon, knowing cardiopulmonary bypass and hemodynamic management, managed the patient’s circulatory and respiratory support during the procedure.
Each will report the CPT code 33945 with modifier 66 since all surgeons involved acted as the primary surgeons while performing distinct and critical parts of the heart transplant surgery.
Accurate Usage Guidelines for Modifier 66
Discussed below are the guidelines related to the appropriate usage of this modifier:
Check the Indicator Value
Always check the indicator column in the Medicare Physician Fee Schedule (MPFS) to know whether team surgeon payment is permitted and modifier 66 is applicable. Here’s what different indicator values represent:
- Indicator 0: Team surgeons are not allowed for this procedure
- Indicator 1: Team surgeons are permitted, but supporting documentation establishing medical necessity is required
- Indicator 2: Team surgeons are permitted, to pay ‘by report’
For the unversed, procedures that are paid ‘by report’ do not have base maximum value, and the insurance company may reimburse the amount they deem suitable for the services based on the submitted documentation.
Do Not Use for Two or Fewer Surgeons
Avoid using the modifier 66 if there are two or fewer surgeons involved in a particular procedure.
All Physicians Must Append 66 with the Same CPT Code
This modifier is applicable to complex procedures covered under a single CPT code, and each surgeon will report the same CPT code by appending it with modifier 66.
Use for Organ Transplant Team Surgeries
This modifier generally applies to organ transplant teams.
Provide Complete Documentation
You should ensure comprehensive documentation when appending this modifier. That is, it must include details about each surgeon’s role during the reported surgical procedure.
Modifier 66 vs 82 – Understanding the Difference
Below is an at-a-glance table with the key differences between modifiers 82 and 66:
| Modifier 66 | Modifier 82 | |
|---|---|---|
| Description | Indicates a surgical team, with each surgeon acting as a primary surgeon who worked on a distinct and critical part of the procedure. | Indicates that a physician acted as an assistant surgeon during a surgical procedure when a qualified resident surgeon was not available. |
| Application | Complex procedures requiring multiple primary surgeons | Assistant surgeon services |
| No. of Surgeons | More than two | One |
| Setting | No limitations | Teaching hospitals only |
Modifier 66 is appended to the relevant procedural code when a highly complex surgery requires a team of surgeons (more than two) to perform each distinct part of the procedure as a primary surgeon. These surgeons can be from the same specialty or different specialties. Thus, each surgeon appending 66 will be considered a primary surgeon for their respective part in the surgery.
Contrarily, modifier 82 is used when an assistant surgeon performs the procedure because a qualified resident surgeon is unavailable in a teaching hospital setting. Besides, this modifier is specific to teaching hospital settings and may not be appropriate if the surgeon provided services in other settings.
Summary
Let’s quickly wrap up by revisiting what we learned throughout this guide! We explained that modifier 66 is used when a team of surgeons (three or more) work together on a surgical procedure as primary surgeons. Besides, we shared some examples where this modifier may apply, including kidney, lung, and heart transplants.
Moving forward, we shared the billing guidelines related to this modifier. Also, we discussed the differences between modifiers 82 and 66. We hope this guide will help you understand where and how to report this modifier to ensure rightful reimbursement. However, if you find medical coding and the concept of modifiers challenging to gauge, we recommend you outsource medical coding to professionals like MediBillMD.
Frequently Asked Questions
