Surgery in workers’ compensation cases opens a Pandora’s box: reserves go up, nurse case managers get involved, and surgeons need to justify every detail of their billing to a non-physician. Getting an extra set of hands to help in the operating room compounds the frustration and reimbursement for the assistant surgeon can be confusing.

Fortunately, the California Official Medical Fee Schedule (OMFS) follows Medicare’s manual, almost word for word. Here, we present a handy guide to billing for surgical assistance.

Co-Surgery vs. Team Surgery: What’s the Difference?

The following is a summary of the differing roles of a co-surgeon versus a team surgery:

Co-surgeon or team surgery - Per 8 CCR §9789.16.7: “Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition. In these cases, the additional physicians are not acting as assistants-at-surgery.”

1. Co-surgeon - Two surgeons, each in a different specialty

1. Each surgeon bills for the procedure with a modifier -62

2. Team surgery - More than 2 surgeons of different specialties

1. Each surgeon bills for the procedure(s) with a modifier -66

3. Reimbursement

1. Co-surgeon (modifier -62) reimbursement is 62.5 percent of the global surgery fee schedule amount.
2. Team surgeon (modifier -66) reimbursement is on a “By Report,” basis
3. If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services.

When Is Co-Surgery vs. Team Surgery Warranted?

Not all surgeries qualify for a co-surgeon or team surgery. To determine whether a surgical CPT code qualifies for either requires you to reference the Medicare Physician Fee Schedule RVU information for the specific surgical CPT code.

The Medicare Physician Fee Schedule RVU table is a rich, but dizzying, spreadsheet chock full of data that the uninitiated will find difficult to navigate. To get the current RVU file for dates of service in 2019 go to the CMS website, then:

1. Download RVU19A.zip;
2. Open PPRRVU19_V1213.xlsx (or .csv or .txt);
3. Find the relevant CPT.

1. There are two columns in the spreadsheet entitled:

1. “Co-Surg,” or Co-Surgeon (column V)
2. “Team Surg,” or Team Surgery (column W)

2. Each column has an assigned indicator as follows:

1. “0” indicates the additional assistance may be allowed, and any documentation submitted with the claim should be reviewed to identify support for the need for additional assistance
2. “1” indicates no additional assistance is allowed.
3. “2” indicates the additional assistance is allowed

Required Documentation for Co-Surgery and Team Surgery Reimbursement

According to 8 CCR §9789.16.7 the assigned indicator in the Medicare RVU table dictates the required documentation for reimbursement as follows:

1. An indicator of “0” -  no payment is allowed, regardless of the supporting documentation.
2. An indicator of “1” - any documentation submitted with the claim should be reviewed to identify support for the need for co-surgeons
3. An indicator of “2” - payment rules for co-surgeon or team surgery apply. The regulations clearly indicate, no supporting documentation is required for reimbursement.

But Wait… There’s an Easier Way

Finding whether a procedure allows for a co-surgeon or team surgery is straightforward with DaisyBill’s easy-to-understand software. Subscribe to DaisyBill’s Wizard and use the OMFS Calculator to look up surgical CPT codes to determine whether the code allows for co-surgeons or team surgeons. For each procedure code, the OMFS Calculator displays the “Co-Surg” or “Team Surg” columns with the assigned indicators. No need to go through CMS’ massive spreadsheet -- we support multiple billing codes and modifiers too.

The OMFS Calculator is one of six powerful products featured in DaisyBill’s Work Comp Wizard. Give it a spin today and see just how easy it is.

OMFS CALCULATOR
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(a) General

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition. In these cases, the additional physicians are not acting as assistants-at-surgery.

(b) Billing Instructions/Determination of Maximum Payment

The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons:

(1) If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62.” Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the Co-Surgeons (“Co Surg”) column of the National Physician Fee Schedule Relative Value File.

• If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “1,” any documentation submitted with the claim should be reviewed to identify support for the need for co-surgeons. If the documentation supports the need for co-surgeons, base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount.
• If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “2,” payment rules for two surgeons apply. The claims administrator shall base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount.
• If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “0,” payment for co-surgeons is not allowed.

(2) If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66.” The Team Surgery (“Team Surg”) column of the National Physician Fee Schedule Relative Value File identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary.

If the surgery is billed with a “-66” modifier and the Team Surgery column contains an indicator of “1,” the claim should be reviewed to identify support for the need for a team of surgeons. If the claims administrator determines that team surgeons were medically necessary, each physician is paid on a “by report” basis.

If the surgery is billed with a “-66” modifier and the Team Surgery column contains an indicator of “2,” the claims administrator shall pay “by report”.

All claims for team surgeons must contain sufficient information to allow pricing “by report.”

(3) If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services.

(4) For co-surgeons (modifier 62), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier 66) is paid for on a “By Report” basis.

NOTE: A fee may have been established for some surgical procedures that are billed with the “-66” modifier. In these cases, all physicians on the team must agree on the percentage of the payment amount each is to receive. If the claims administrator receives a bill with a “-66” modifier after the claims administrator has paid one surgeon the full payment amount (on a bill without the modifier), deny the subsequent claim.

(5) Apply the rules relating to global surgical packages to each of the physicians participating in a co- or team surgery.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.