By Jeri L. Harris
When two surgeons are needed to perform a difficult surgery and each surgeon performs an individual, intricate portion of the surgery, many coding questions arise. What, if any, modifiers are used? Which CPT-4 codes should each surgeon use?
By definition, the surgical assistant modifier "-80" is used only when a physician assists in surgery. The services of a registered nurse or a physician's assistant are included in the primary surgeon's payment for the surgical service and are not paid separately. A surgical assistant must submit a separate claim, which includes the same CPT-4 codes used by the primary surgeon, plus the modifier "-80" added. Many times a surgical operative report will be requested to ensure that the assistant surgeon's name is actually listed on the operative report.
In contrast, the modifier "-62" is used under certain circumstances where two surgeons (usually with different skills) may be required to the management of a specific surgical procedure. Under such specific circumstances, adding the modifier "-62" to the procedure code used by each surgeon reporting the procedure(s) may identify the separate services.
When modifier "-62" is used, no allowance is generally made for an assistant surgeon because many insurance carriers believe two surgeons are capable of performing the most intricate and difficult procedures. Under certain circumstances, special consideration could be given for an assistant surgeon, but only if medically justified and documented.
A patient requires a lumbar diskectomy of L4-L5, L5-S1, fusion and instrumentation and iliac crest bone grafting. The treating orthopaedic surgeon decides that, due to the type and location of the herniation and spinal instability, an anterior approach is required. The orthopaedist can either perform that approach himself/herself or, may ask a general thoracic surgeon to perform the opening, gain access and approach, and possibly even perform as assistant surgeon with the major portions of each procedure. When the surgeons are finished with the anterior diskectomy, anterior interbody fusion and anterior instrumentation, the patient's surgery is again handed over to the general thoracic surgeon to finish closing the patient's incision by anterior approach.
First example. The general thoracic surgeon performed and gained access for anterior approach for anterior lumbar diskectomy, then assisted the primary surgeon with the anterior diskectomy, anterior arthrodesis and anterior instrumentation. The closure was performed by the general thoracic surgeon after all other procedures throughout were completed.
The primary surgeon codes: 63090-62, 22558-51 and 22845. The general thoracic surgeon codes: 63090-62, 22558-80 and 22845-80.
The rationale behind the "-62" modifier is that the general thoracic surgeon performed the anterior lumbar approach, then assisted in the major portion of the primary procedure. The primary surgeon required more than just another surgeon's "assistance" for the primary procedure, therefore the primary procedure must be shared equally between both surgeon's. A separate operative report will need to be dictated by the general thoracic surgeon for the anterior approach, plus notated that he/she assisted with the major portions of each procedure, and anterior closure of the surgical wound. The primary surgeon will need to dictate that the anterior approach and closure was performed by and will be dictated under separate operative report by the general thoracic surgeon, then dictate the complete operative report with a notation that the assistant surgeon for the other procedures was the general thoracic surgeon. Some surgeon's separate out the primary procedure, notating both as primary surgeons (both surgeon's dictate operative reports); then dictate primary and assistant surgeon for the rest of the operative report.
Second example. The general thoracic surgeon only gains access for the orthopaedic surgeon anterior approach for the lumbar diskectomy, then exits the operating suite only to return for the surgical closure. The primary surgeon required the assistance of an orthopaedic surgeon to proceed with anterior lumbar arthrodesis and anterior lumbar instrumentation. If the primary surgeon states that he will dictate the entire operative report, he must share the primary procedure with the general thoracic surgeon because the primary surgeon required the assistance of another surgeon to complete the surgical procedure. The procedures would be as follows:
The primary surgeon codes: 63090, 22558-51 and 22845. The general thoracic surgeon codes: 63090-80. The assistant orthopaedist codes: 22558-80 and 22845-80.
The rationale behind the "-80" modifier for the general thoracic surgeon is that he/she shared only the very inherent portions of the primary procedure, didn't dictate a separate operative report, nor assisted with any other procedures. The second orthopaedist did contribute and assisted on all other major portions of the surgery, therefore he/she would be properly reimbursed for that assistance. In the above case, the general thoracic surgeon could bill the primary procedure with the "-80" modifier even if he/she dictated an operative report separately, the primary surgeon required the assistance of the general thoracic surgeon in order to complete the primary surgical procedure.
Jeri L. Harris, CPC, CPC-H works for a large multispecialty orthopaedic practice in Charleston, S.C. She is serving her second year on the National Advisory Board for the American Academy of Procedural Coders.