CurrentColorado Rocky Mountain Health PlansPolicy N/A

Co-Surgeon and Team Surgeon reimbursement

Defines when and how UnitedHealthcare Community Plan reimburses Co-Surgeon (modifier 62) and Team Surgeon (modifier 66) services for claims billed on CMS-1500/UB04 and which procedures are eligible based on CMS NPFS; applies to UnitedHealthcare Community Plan Medicaid products and participating/nonparticipating physicians and practitioners.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCo-Surgeon and Team Surgeon reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor Team Surgeon services each surgeon must submit the same CPT code with modifier 66 and provide written medical documentation describing their specific involvement for case-by-case reimbursement review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

62.5%standard reimbursement rate for each Co-Surgeon

Case-by-caseTeam Surgeon reimbursement

NPFS 1 or 2eligible codes

CMS formsbilling forms

May apply

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Co-Surgeon and Team Surgeon Coverage Criteria

Co-Surgeon/Team Surgeon coverage criteria

Reimbursement rules and limitations for Co-Surgeon (modifier 62) and Team Surgeon (modifier 66) services — covered when the following conditions are met.

ALL of the following

Each Co-Surgeon must submit the same Current Procedural Terminology (CPT) code with modifier 62 for the same date of service.
UnitedHealthcare Community Plan reimburses Co-Surgeon services at 62.5% of the Allowable Amount to each surgeon; the Allowable Amount is determined independently for each surgeon and is calculated from the Allowable Amount that would be given to that surgeon performing the surgery without a Co-Surgeon.
Multiple procedure reductions apply to Co-Surgeon claim submissions when one or more physicians bill multiple CPT codes that are eligible for reductions.

ALL of the following

Each Team Surgeon must submit the same CPT code with modifier 66 for the same date of service.
Each Team Surgeon is required to submit written medical documentation describing the specific surgeon's involvement in the total procedure.
UnitedHealthcare Community Plan will review submissions with documentation and make reimbursement decisions on a case-by-case basis for services eligible for Team Surgeon.

ALL of the following

Codes eligible for Co-Surgeon or Team Surgeon billing are those identified in the CMS Nonphysician Practitioner Fee Schedule (NPFS) or CMS PFS indicator lists as status indicator '1' or '2' (payer references CMS NPFS/Relative Value Files for procedure applicability).

ALL of the following

Assistant surgeon modifiers (80, 81, 82, or AS) are not reimbursed for procedures where reimbursement has been provided for eligible Co-Surgeon services using the same surgical procedure code during the same encounter.
If a Co-Surgeon acts as an Assistant Surgeon for additional separate procedure(s) during the same surgical session, those additional procedures may be reimbursable (if eligible per the Assistant Surgeon Eligible List) when billed with separate procedure code(s) and the appropriate assistant surgeon modifier (80 or 82).

ALL of the following

For simultaneous bilateral procedures (each surgeon performs the same procedure on opposite sides), each surgeon should report the procedure with modifiers 50 and 62.
Assistant Surgeon services will not be reimbursed in addition to the simultaneous bilateral submission as described in the Assistant Surgeon and Co-Surgeon Services section.

State exceptions (override standard policy when applicable)

Florida: modifier 62 reimbursed at 50% and modifier 66 reimburses up to 3 providers at 100% of maximum allowable, per state regulations.
Indiana: specified CPT/HCPCS codes are not covered for Indiana per regulations (see policy for list).
Kentucky: modifier 62 reimbursed at 50% of the allowed amount for KY Medicaid.
Massachusetts: modifier 62 reimbursed at 57.50% of the allowable amount per state regulations.
Mississippi: modifier 66 reimbursed at 62.5% of the Allowable Amount for MS CAN.
New Mexico: total allowed value of the procedure is increased by 25% and each surgeon is paid 50% of that amount.

ALL of the following

UnitedHealthcare applies payment indicators per CMS files when adjudicating applicability of Co-Surgeon/Team Surgeon services (see policy crosswalks for specific CPT/HCPCS mappings).

Modifiers and Reimbursement Details

Modifiers for surgeon rolesModifierCovered

62	Co-Surgeon modifier; appended to CPT code to identify co-surgeon services
66	Team Surgeon modifier; appended to CPT code to identify team surgeon services

Co-Surgeon reimbursement rate

Reimbursement rate62.5% of the Allowable Amount to each surgeon

ApplicationEach Co-Surgeon must submit the same CPT code with modifier 62 for the same date of service

Multiple procedure reductionsSubject to additional multiple procedure reductions when applicable

Allowable Amount calculationAllowable Amount is determined independently for each surgeon and calculated from the amount that would be given to that surgeon performing the surgery without a Co-Surgeon

Documentation and Billing Requirements

Documentation Required

Team Surgeon (modifier 66) documentation and eligible code requirements

For Team Surgeon services (modifier 66), each participating surgeon must submit the identical CPT code appended with modifier 66 for the same date of service and provide written medical documentation that describes that surgeon’s specific involvement in the total procedure. UnitedHealthcare Community Plan will review each submission and its accompanying documentation and adjudicate reimbursement on a case-by-case basis. Codes eligible for Team Surgeon or Co-Surgeon billing are those in the CMS NPFS with status indicators "1" or "2."

Submit the same CPT code with modifier 66 for the same date of service.
Include written medical documentation describing the specific surgeon’s involvement.
Eligible procedure codes are those with NPFS status indicators "1" or "2" for Team Surgeons/Co-Surgeons.

Key Term Definitions

Allowable Amount

DefinitionThe dollar amount eligible for reimbursement to the Physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges). For percent of charge or discount contracts, the Allowable Amount is the billed amount less the discount).

Use in policyUsed to calculate Co-Surgeon payments (each Co-Surgeon reimbursed as a percentage of the Allowable Amount)

DeterminationCalculated per provider and per procedure as applicable to the claim and contract type

Assistant Surgeon

DefinitionA physician or other qualified health care professional who is assisting the physician performing a surgical procedure.

ModifiersAssistant surgeon services are reported with assistant surgeon modifiers (e.g., 80, 81, 82, AS) when applicable