CurrentAnthemPolicy G-06039

Modifier 66 (surgical team) reimbursement

Defines Anthem (AMH Health) reimbursement policy for procedures billed with Modifier 66 (surgical team), including documentation, billing and fee reduction interactions, and prepayment review requirements for providers submitting claims.

Policy Summary

PayerAnthem (AMH Health)

PolicyModifier 66 (surgical team) reimbursement

Policy CodePolicy G-06039

Change TypeNo material changes

Effective DateAug 7, 2020

Next Review Date

Key ActionSubmit supporting documentation with claims billed with Modifier 66 to pass prepayment review; claims without documentation will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prepayment review requiredPrepayment review required

documentation requiredClaims denied without documentation

multiple procedure rules applyMultiple procedure rules

assistant surgeon rules exemptAssistant surgeon rules exempt

policy references CMSPolicy references CMS & contracts

Modifier 66 — Coverage and Billing Criteria

Modifier 66 billing and coverage criteria

Coverage and billing rules for surgical team services billed with Modifier 66.

Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66.

Providers must submit supporting documentation with claims billed with Modifier 66; claims submitted without documentation will be denied.

AMH Health performs a prepayment review to support the use of Modifier 66; documentation must be provided with the claim or it will be denied.

If physicians participating in the surgery fail to use Modifier 66 appropriately, claims may be denied or pended for duplicate or suspected duplicate services.

Multiple procedure rules and fee reductions apply if the surgical team performs multiple procedures unless surgeons of different specialties are each performing a different procedure.

Policy Summary

PayerAnthem (AMH Health)

PolicyModifier 66 (surgical team) reimbursement

Policy CodePolicy G-06039

Change TypeNo material changes

Effective DateAug 7, 2020

Next Review Date

Key ActionSubmit supporting documentation with claims billed with Modifier 66 to pass prepayment review; claims without documentation will be denied.

SourceLink

On This Page

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Assistant surgery rules and fee reductions apply if any member of the surgical team acts as an assistant performing additional procedure(s) during the same surgical session.

Assistant surgeon rules do not apply to procedures appropriately billed with Modifier 66.

Relevant Codes and Documentation Thresholds

ModifierModifier

Modifier 66

Modifier indicating surgical team service; appended to procedure code(s) for each participating physician.

Documentation threshold — Modifier 66 claims

RequirementDocumentation must be submitted with claims billed with Modifier 66.

ConsequenceClaims submitted without the required documentation will be denied.

Review processAMH Health conducts prepayment review to support the use of Modifier 66 and to validate submitted documentation.

Billing expectationEach physician in the surgical team must bill the applicable procedure code(s) with Modifier 66 for their individual services.

Provider Billing Requirements and Prepayment Review

Prior Authorization

Prepayment review and documentation requirement for Modifier 66

AMH Health performs a prepayment review to support the use of Modifier 66. Providers must submit documentation with claims billed with Modifier 66; claims submitted without documentation will be denied.

Submit supporting documentation with every claim billed with Modifier 66 to satisfy the prepayment review.
Failure to submit documentation will result in claim denial.

Key Definitions

Modifier 66 (surgical team) — definition and usage

DefinitionModifier 66 identifies services performed under the surgical team concept when highly complex procedures require concomitant services of several physicians or other qualified healthcare professionals; it is appended to the basic procedure number.

When to useUse Modifier 66 when multiple physicians of potentially different specialties participate in a single, highly complex surgical procedure and each reports their individual procedure code(s).

Billing requirementEach participating physician must append Modifier 66 to their procedure code(s); failure to do so may result in claims being denied or pended for duplicate or suspected duplicate services.

Interaction with other rulesMultiple procedure rules and fee reductions apply when the surgical team performs multiple procedures unless surgeons of different specialties each perform a different procedure; assistant surgeon rules do not apply to procedures appropriately billed with Modifier 66.