California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.16.7 - Surgery - CO-Surgeons and Team Surgeons

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.