(Medicare Claims Processing Manual)

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 patients condition.  In these cases, the additional physicians are not acting as assistants -at-surgery.   B.  Billing Instructions   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:    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 MFSDB.  (See 40.8.C.5 .);   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.  Field 25 of the MFSDB identifies certain services submitted with a  -66 modifie r which must be sufficiently documented to establish that a team was medically necessary.  All claims for team surgeons must contain sufficient informatio n to allow pricing by report.    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 surgeons services.  (See 40.6 for multiple surgery payment rules.)   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.  C.  Claims Processing System Requirements  Carriers must be able to:   1. Identify a surgical procedure performed by two surgeons or a team of surgeons by the presence on the claim form or electronic submission of the  -62 or  -66 modifier;   2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;   3. Access Field 24 or 25, as appropriate, of the MFSDB.  These fields provide guidance on whether two or team surgeons are generally required for the surgical procedure;   4. If the surgery is billed with a  -62 or  -66 modifier and Field 24 or 25 contains an indicator of 0, payment adjustment rules for two or team surgeons do not apply:    Carriers pay the first bill submitted, and base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply;    Carriers deny bills received subsequently from other physicians and use the appropriate MSN message in 40.8.D .   As these are medical necessity denials, the instructions in the Program Integrity Manual regarding denial of unassigned claims for medical necessity are applied;   5. If the surgery is billed with a  -62 modifier and Field 24 contains an indicator of 1, suspend the claim for manual review of any documentation submitted with the claim.  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 (Field 34 or 35);   6. If the surgery is billed with a  -62 modifier and Field 24 contains an indicator of 2, payment rules for two surgeons apply.  Carriers base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);   7. If the surgery is billed with a  -66 modifier and Field 25 contains an indicator of 1, carriers suspend the claim for manual review.  If carriers determine that team surgeons were medically necessary, each physician is paid on a by report basis;  8. If the surgery is billed with a  -66 modifier and Field 25 contains an indicator of 2, carriers pay by report;   NOTE:  A Medicare 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 Medicare payment amount each is to receive.  If carriers receive a bill with a  -66 modifier after carriers have paid one surgeon the full Medicare payment amount (on a bill without  the modifier), deny the subsequent claim.  9. Apply the rules global surgical packages to each of the physicians participating in a co-  or team surgery; and   10. Retain the - 62 and  -66 modifiers in history for any co-  or team surgeries.   D.  Beneficiary Liability on Denied Claims for Assistant, Co-  surgeon and Team Surgeons   When the procedure is subject to the statutory restriction against payment for assistants -at-surgery, such payment shall be denied.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.11  Carriers include the following statement in the MSN: "You cannot be charged for this service. (Unnumbered add -on message.)   If Field 23 of the MFSDB contains an indicator of 0 or 1 (assistant -at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  For those procedures with an indicator of 0, the limitation on liability provisions described in Chapter 30 apply to assigned claims.  Therefore, carriers include the appropriate limitation of liability language from Chapter 21.  For unassigned claims, a pply the rules in the Program Integrity Manual concerning denial for medical necessity. Where payment may not be made for a co - or team surgeon, deny the claim   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.13  Where payment may not be made for a two surgeons, deny the claim.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  Also see limitation of liability remittance notice Remittance Advice Remark Code Alert M27 and use when appropriate.   40.9 - Procedures Billed With Two or More Surgical Modifiers  (Rev. 1, 10- 01-03) B3-4829 A/B MACs (B) may receive claims for surgical procedures with more than one surgical modifier.  For example, since the global fee concept applies to all major surgeries, A/B MACs (B) may receive a claim for surgical care only (modifier - 54) for a bilateral surgery (modifier -50).  They ma y also receive a claim for multiple surgeries requiring the use of an assistant surgeon.  Following is a list of possible combinations of surgical modifiers.  (NOTE:  A/B MACs (B) must price all claims for surgical teams by report.)   Bilateral surgery (- 50) and multiple surgery ( -51).   Bilateral surgery (- 50) and surgical care only ( -54).   Bilateral surgery (- 50) and postoperative care only ("55).   Bilateral surgery (- 50) and two surgeons ( -62).  Bilateral surgery (- 50) and surgical team (- 66).   Bilateral surgery (- 50) and assistant surgeon ( -80).   Bilateral surgery (- 50), two surgeons ( -62), and surgical care only ( -54).   Bilateral surgery ( -50), team surgery ( -66), and surgical care only ( -54).   Multiple surgery ( -51) and surgical care only ( -54).   Multiple surgery ( -51) and postoperative care only ("55).   Multiple surgery ( -51) and two surgeons ( -62).  Multiple surgery ( -51) and surgical team (- 66).   Multiple surgery ( -51) and assistant surgeon ( -80).   Multiple surgery ( -51), two surgeons ( -62), and surgical care only ( -54).   Multiple surgery ( -51), team surgery (- 66), and surgical care only ( -54).   Two surgeons ( -62) and surgical care only ( -54).   Two surgeons ( -62) and postoperative care only (55).   Surgical team ( -66) and surgical care only ( -54).   Surgical team ( -66) and postoperative care only (55).  Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier  -62) or team surgeons (modifier  -66) is appropriate.  If A/B MACs (B) receive a bill for an assistant surgeon following payment for co- surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.  50 - Payment for Anesthesiology  Services  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17)  A. General Payment  Rule   The fee schedule amount for physician anesthesia services furnished is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure i s communicated to the A/B MACs by means of the HCPCS file released annually.  CMS releases the conversion factor annually.  The base units and conversion factor are available on the CMS website at: https://www.cms.gov/Center/Provider -Type/Anesthesiologists -Center.html.     B. Payment at Personally Performed  Rate   The A/B MAC must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time  if:   The physician personally performed the entire anesthesia service alone;    The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in 100;    The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case that meets the requirement s for payment at the medically directed rate. The physician meets the teaching physician criteria in 100.1.4;    The physician is continuously involved in a single case involving a student nurse  anesthetist;   If the physician is  involved with  a single  case with a qualified nonphysician anesthetist (a certified registered nurse anesthetist ( CRNA)  or an anesthesiologists assistant)),  A/B  MACs  may pay the physician service and  the qualified nonphysician anesthetist  service in accordance with the requirements for payment at the medically directed rate;    Or   The physician and the CRNA (or anesthesiologists assistant) are involved in one anesthesia case and the services of each are found to be medically necessary.  Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the AA  modifier and the CRNA reports the QZ modifier.   C. Payment at the Medically Directed  Rate   The A/B MAC determines payment at the medically directed rate for the physician on the basis of 50 percent of the allowance for the service performed by the physician alone. Payment will be made at the medically directed rate if the physician medically dir ects qualified individuals (all of whom could be CRNAs, anesthesiologists assistants, interns, residents, or combinations of these individuals) in two, three, or four concurrent cases and the physician performs the following activities.    Performs a pre -anesthetic examination and  evaluation;    Prescribes the anesthesia plan;    Personally participates in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence;    Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified  individual;    Monitors the course of anesthesia administration at frequent  intervals;   Remains physically present and available for immediate diagnosis and treatment of emergencies;  and   Provides indicated post -anesthesia care.