Policy #: 111 Latest Review Date: January 2010

Transcription

1 Name of Policy: Co-surgeons and Team Surgeons Policy #: 111 Latest Review Date: January 2010 Category: Administrative Policy Grade: N/A Background: As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts to have such coverage. The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage: 1. The technology must have final approval from the appropriate government regulatory bodies; 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes; 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternatives; 5. The improvement must be attainable outside the investigational setting. Coding: Modifiers: -62 Two Surgeons: when two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier - 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) are performed during the same surgical session, separate code(s) may also be reported with the modifier -62 added. -66 Surgical Team: under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the surgical team concept. Such circumstances may be identified by each participating physician with the addition of the modifier -66 to the basic procedure number used for reporting the services. -22 Unusual Procedure Services: when the service(s) provided is greater than Proprietary Information of Blue Cross and Blue Shield of Alabama 1

2 that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number. A report may also be appropriate. -80 Assistant Surgeon: Surgical assistant service may be identified by adding the modifier -80 to the usual procedure number(s). Description of Procedure or Service: Category I: Co-surgery termed as Single Shared Co-surgery o Surgical procedure requires two or more surgeons who usually have different types of skill and expertise to perform a single procedure, which has two separate but integrated parts, performed during the same operative session under the same anesthesia. o Example: Procedure (Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion;) or code (hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) frequently requires a neurosurgeon and otolaryngologist; or procedure (Creation of shunt; ventriculo-peritoneal, - pleural, other terminus) frequently requires the skills of a neurosurgeon and general surgeon. Both surgeons would bill the same procedure code. o Modifier -62 is used. Effective for dates of service on or after April 28, 2006: o Example: Procedure Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); lumbar which may or may not be billed with Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure) may require the skills of a general surgeon and a neurosurgeon and/or orthopaedic surgeon. o Modifier -62 is used. Category II: Classified as Multiple Shared Co-surgery o Involves two physicians with different skills billing for different surgical procedures under the same anesthesia o Example: Procedure Laminectomy with explorations and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis). More than 2 vertebral segments; cervical; billed with Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments, and Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment may require the skills of a neurosurgeon and an orthopedic surgeon. Each surgeon would bill the procedure code he or she performed. o Example: An urologist performs procedure Abdomino-vaginal vesical neck suspension, with or without endoscopic control (e.g., Stamey, RAZ, Modified Pereyra) and a gynecologist performs a hysterectomy (58150-Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or Proprietary Information of Blue Cross and Blue Shield of Alabama 2

3 without removal of ovary(s)). Note that this applies to a urologist and gynecologist. If a gynecologist has specialized training in performing urological procedures and performs a urological procedure and a separate gynecologist performs the hysterectomy, this is not co-surgery or team surgery. o Example: A general surgeon performs Mastectomy, radical, including pectoral muscles, axillary lymph nodes and a plastic surgeon performs Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site. o Example: A gynecologist performs a hysterectomy and there are procedural complications such as a perforated bowel requiring a general surgeon to repair. o Modifier -62 is used. Effective for dates of service prior to April 28, 2006: o Example: Procedure Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); lumbar which may or may not be billed with Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); each additional interspace (list separately in addition to code for primary procedure) may require the skills of a general surgeon and a neurosurgeon and/or orthopaedic surgeon. Category III: Shared Care Surgery or Bilateral Procedures o Involves two physicians with the same surgical skills who are performing bilateral procedures under the same anesthesia. o Example: Bilateral total knee replacement. o Modifier -62 is used Category IV: Unrelated Co-surgery or Team Surgeons o Requires two or more surgeons with the same or different skills that are operating in different operative fields under the same anesthesia and is frequently performed due to trauma. o Example: A general surgeon performs a splenectomy and an orthopedic surgeon performs an open reduction internal fixation (ORIF) of the femur during the same anesthesia session. o Modifier -66 is used. o Example: An ear, nose and throat (ENT) physician performs placement of tubes in the ear (69436) at the same time as a urologist performs a circumcision (54161) or foreskin manipulation including lysis of preputial adhesions and stretching (54450). Category V: Related Co-surgery or Team Surgeons o Performed for a very complex surgical procedure such as an organ transplant. o Modifiers -66 and -22 are used. Policy: Blue Cross and Blue Shield of Alabama will treat Category I as Co-Surgeons with 150% of the allowance for the procedure divided equally between the two surgeons. Multiple surgery Proprietary Information of Blue Cross and Blue Shield of Alabama 3

4 guidelines will apply if a surgeon performs more than one procedure. Both providers must use modifier -62 on their claims. Blue Cross and Blue Shield of Alabama will treat Category II as Multiple Shared Co-surgery with each provider reimbursed at 100% of the allowance for their procedures. Multiple surgery guidelines will apply if a surgeon performs more than one procedure. Both providers must use modifier -62 on their claims. If a surgeon has the skills to perform all parts of a multiple shared co-surgey procedure, this is not co-surgery or team surgery and this will be reimbursed with one surgeon considered the primary surgeon (100%) and the other surgeon will be reimbursed as an assistant surgeon (25%). The assistant surgeon must use modifier- 80. For example, a gynecologist has specialized training in performing urological procedures and performs a urological procedure and a separate gynecologist performs the hysterectomy. Blue Cross and Blue Shield of Alabama will treat Category III as Shared Care Surgery or Bilateral Procedures with 150% of the allowance for the procedure divided equally between the two surgeons. Multiple surgery guidelines will apply if a surgeon performs more than one procedure. Both providers must use modifier -62 on their claims. Blue Cross and Blue Shield of Alabama will treat Category IV as Unrelated Co-surgery or Team Surgery with each provider reimbursed at 100% of the allowance for their procedures. Multiple surgery guidelines will apply if a surgeon performs more than one procedure. Both providers must use modifier -66 on their claims. Blue Cross and Blue Shield of Alabama will treat Category V as Related Co-surgery or Team Surgery with each provider reimbursed at 100% of the allowance for their procedures. Multiple surgery guidelines will apply if a surgeon performs more than one procedure. Both providers must use modifier -66 and -22 on their claims. In cases requiring co-surgeons or team surgeons, an second assistant surgeon is usually not covered. In all the above instances, if an second assistant surgeon is utilized, individual consideration will be used to determine if the second assistant surgeon will be covered. For example: If a general surgeon bills as co-surgeon on 22558, then he is paid to assist in the entire procedure not just the laparotomy portion. If he only performs assists in the lap, he/she should have billed Therefore, if an assistant surgeon is billed when co-surgeons (an orthopedic and neurosurgeon) have both billed 22558, the assistant surgeon would not be covered. If two unrelated surgery are performed by different specialities at the same time and the surgeons do not assist each other then an assistant surgeon could be considered if determined to be medically necessary. An example of this would be a general surgeon performing a lap inguinal hernia repair at the same time that a plastic surgeon is doing breast reconstruction. An assistant could be considered for the breast reconstruction since the general surgeon did not bill as co-surgeon for this procedure. Nurse practitioners and physician assistants are not eligible to bill as a co-surgeon. Blue Cross and Blue Shield of Alabama does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether Proprietary Information of Blue Cross and Blue Shield of Alabama 4

5 or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. Blue Cross and Blue Shield of Alabama administer benefits based on the members' contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination. Key Points: Not applicable Key Words: Co-surgeon, co-surgery, team surgeon, team surgery, shared care surgery, multiple shared cosurgery, unrelated co-surgery, unrelated team surgery, related co-surgery, related team surgery Approved by Governing Bodies: Not applicable Benefit Application: Coverage is subject to member s specific benefits. Group specific policy will supersede this policy when applicable. References: 1. Current Procedure Terminology CPT American Medical Association. AMA Press. Policy History: Medical Review Committee, September 1994 Medical Policy Group, May 2003 (2) Medical Policy Administration Committee, May 2003 Available for comment June 3-July 18, 2003 Medical Policy Group, April 2005 (2) Medical Policy Administration Committee, April 2005 Available for comment April 13-May 27, 2005 Medical Policy Group, March 2006 (3) Medical Policy Administration Committee, March 2006 Available for comment March 14-April 27, 2006 Medical Policy Group, July 2007 (3) Medical Policy Administration Committee, July 2007 Medical Policy Group, January 2010 (3) Medical Policy Administration Committee, January 2010 Available for comment January 26-March 11, 2010 This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case by case basis according to the terms of the member s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment. Proprietary Information of Blue Cross and Blue Shield of Alabama 5

6 This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review)in Blue Cross and Blue Shield s administration of plans contracts. Proprietary Information of Blue Cross and Blue Shield of Alabama 6