CurrentHighmark Blueshield NenyPolicy RP-002

Co-Surgery

Governs reimbursement and billing for co-surgery (two or more surgeons acting as primary surgeons) for applicable Highmark BlueShield markets and claim types.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCo-Surgery

Policy CodePolicy RP-002

Change TypeNo material changes

Effective DateAug 1, 2016

Next Review Date

Key ActionEach co-surgeon must append Modifier 62 to the primary CPT code on their claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

62.5%reimbursement rate per co-surgeon

PA, WV, DE, NYmarkets listed

Modifier 62required modifier

1500applicable claim type

Co-surgery Coverage and Payment Criteria

inv-01: Co-surgery payment and billing criteria

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Co-surgery must be performed during the same operative session with two or more surgeons performing distinct parts as primary surgeons.

Plan reimbursement: The Plan will reimburse co-surgery procedures at 62.5% of the contract allowance, per surgeon per procedure.

Modifier requirements: Each co-surgeon must append Modifier 62 to the primary CPT code to indicate co-surgery; Modifier 62 should not be used when a surgeon acts as an assistant surgeon.

Billing consistency: Procedure and diagnosis codes should be the same on each co-surgeon's claim; billed amounts may differ between surgeons.

Regional note: Delaware reimbursement references Chapter 12 of the Medicare Claims Processing Manual.

inv-02: Co-Surgery payment and billing criteria

Payment and billing criteria for co-surgery procedures:

Reimbursement rate: Reimburse co-surgery at 62.5% of the contract allowance per surgeon per procedure.

Modifier 62 required: Each co-surgeon must append Modifier 62 to their claim; do not use Modifier 62 when acting as an assistant surgeon.

Coding consistency: Procedure and diagnosis codes must be the same on each co-surgeon's claim; billed amounts may differ.

Jurisdictional reference: Delaware reimbursement references CMS Pub. 100-04 Chapter 12 (Medicare Claims Processing Manual, Chapter 12).

See related policies: Refer to Commercial (S-112) and Medicare Advantage (N-112) co-surgery policies for additional information.

Coding, Modifiers, and Payment Share

ModifierModifierCovered

62	Modifier 62 = Co-Surgery; appended to each co-surgeon's primary CPT code

ModifierModifierCovered

62	Modifier 62 — co-surgeon

Reimbursement share per surgeon

Reimbursement rate62.5% of the contract allowance per surgeon per procedure

ScopeApplies per surgeon for each co-surgery procedure

Regional noteDelaware reimbursement references Chapter 12 of the Medicare Claims Processing Manual

Payment percentage per co-surgeon

Payment percentage62.5% of the contract allowance per surgeon per procedure

Per-procedure basisPaid to each co-surgeon for the same operative session

ReferencePolicy restates the 62.5% rate in multiple sections of the document

Billing and Modifier Requirements for Providers

Billing Rule

Modifier 62 billing requirement

Both surgeons must agree to append Modifier 62 on their claim. Modifier 62 should not be used when a surgeon acts as an assistant surgeon.

Billing Rule

Billing and modifier requirements

Both surgeons must agree to append modifier 62 on their claim; modifier 62 should be appended to each co-surgeon's claims. Procedure and diagnosis codes should be the same on each co-surgeon's claim; billed amounts may differ. Modifier 62 should not be used when a surgeon acts as an assistant surgeon.

Append modifier 62 to each co-surgeon's primary CPT code.
Ensure procedure and diagnosis codes match on each co-surgeon's claim.
Billed amounts may differ between co-surgeons.

Definitions

Co-Surgery / Co-Surgeons

DefinitionTwo or more surgeons working together simultaneously as primary surgeons to perform distinct parts of an operative procedure during the same operative session.

Operative timingCo-surgery is always performed during the same operative session.

Role distinctionEach surgeon performs distinct parts of the operation as a primary surgeon, not as an assistant.

Modifier 62

Modifier 62 definitionAppended to the primary CPT code by each co-surgeon to indicate co-surgery.

ProhibitionModifier 62 should not be used when a surgeon acts as an assistant surgeon.

Co-Surgeon / Co-Surgery

DefinitionCo-Surgeons are two or more surgeons, working together simultaneously as primary surgeons, to perform distinct parts of an operative procedure during the same operative session.

Distinction from assistantThe additional physician is not considered an assistant when functioning as a co-surgeon.