The January 2021 updated OIG Work Plan makes it clear that the Office of the Inspector General (OIG) is paying attention to surgical modifier 62. The Work Plan states.billing modifier 62.
“…we plan to audit a sample of claim line items specifically where different physicians billed for the same co-surgery procedure code, for the same beneficiary, on the same date of service. Our objective is to determine whether Part B payments to physicians for co-surgery procedures were properly made.”
Reminder: Modifier 62 indicates that the services of two or more surgeons were required for the same procedure(s), during the same operative session, on the same patient, on the same date of service.
Modifier 62 is tricky. To use this modifier correctly, there are several straightforward rules that might make you think usage should be a piece of cake. These include:
- Different Specialties: To be paid as co-surgeons, each surgeon must have a different specialty. The same specialty but different subspecialties doesn’t qualify for payment.
- Dual Modifier Usage: Both surgeons must append modifier 62 to the procedure code when filing their separate claims. That alerts Medicare to pay each surgeon 62.5% of the fee schedule.
- Diagnosis Code Linkage: The procedure code should also be linked to the same diagnosis code on both claims.
However, there a couple of modifier 62 application rules that you’ll need to pay close attention to. Getting them wrong will almost certainly get you audited. Here are the more complex rules you’ll need to master to correctly utilize modifier 62.
Medical Necessity Drives Use of Modifier 62
Medicare requires documentation that the procedure (or the patient’s condition) was of a nature that two surgeons of different specialties were medically necessary. This is identified in Medicare Physician Fee Schedule by an indicator next to the procedure code of 0, 1 or 2. Here are the Medicare rules of when co-surgeons (and modifier 62) are permitted:billing modifier 62.
- “0” Indicator: Co-surgeons are not permitted and will not be paid
- “1” Indicator: Co-surgery is allowed and may be paid based on proper supporting documentation
- “2” Indicator: Co-surgery is allowed and will be paid without having to submit additional documentation
Assisting Surgeon vs. Co-surgeon: Know the Difference when Billing Modifier 62
Incorrectly billing an assisting surgeon as a co-surgeon will result in an overpayment (and possibly a later recoupment of that money by the payer). Co-surgeons each receive 62.5% of the fee schedule amount, for a total of 125%. A physician assisting receives only 16% of the fee (while the lead surgeon receives 100%), for a total of 116% of the fee schedule amount. billing modifier 62.
WARNING: Just because two surgeons have different specialties doesn’t mean they automatically get categorized as co-surgeons in terms of billing modifier 62. To qualify, each surgeon must act as the lead surgeon for their portion of the procedure. Of course, this must be clearly documented in both surgeons’ op notes. Also, co-surgeons cannot share one op note that refers to the surgeons as “we.” In order to utilize modifier 62 and be paid as a co-surgeon, each surgeon must document their part of the procedure separately, so that when you put the op notes together, you have the full procedure.
Overpayments for Modifier 62 Misuse
The 2020 Medicare Fee-for-Service Supplemental Improper Payment Data report published by HHS, indicates that last year the Agency overpaid 7.8% of Part B outpatient claims for a total of $8.1 Billion. And you can bet that they want it back.
Failing to apply modifier 62 on a justifiable claim will most certainly result in you being overpaid. This happens because by applying modifier 62 you are telling the payor to pay your claim out at 62.5% (vs. 100%). So, failure to apply this modifier when it should be used will result in an overpayment of 37.5% on your claim.
To make things worse, if modifier 62 is missing from both claims, both will be paid at 100%, resulting in a 75% overpayment in total.
Accordingly, payers are on the lookout for modifier 62 overpayments. When billing co-surgery, modifier 62 must be appended to the procedure code on each surgeon’s claim. Failure to do so will most certainly send up a red flag to payers and could result in a costly, stressful audit. Something you most certainly do NOT want.
To learn more about how to correctly utilize modifier 62 and other surgical modifiers check out the online training, Boost Surgical Modifier Pay-up and Avoid Audit Penalties, being presented live by national coding expert, Kim Huey MJ, CHC, CPC, CCS-P, PCS, CPCO. This practical, must attend training is being held online on Thursday, March 25th, 60 minutes – 1pm ET. To attend, simply register online.
Note: You can read the January 2021 updated OIG Work Plan in its entirety on the OIG website.
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