CurrentUnitedHealthcarePolicy 2025R9010B

Medicare Advantage CMS 1500 Reimbursement Policy — Co‑Surgeon, Team Surgeon, and Assistant Surgeon Billing

Defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on the CMS 1500 form, including payment and documentation requirements for co-surgeons (modifier 62), team surgeons (modifier 66), multiple procedure reductions, and interactions with assistant surgeon billing. Applies to network physicians and qualified health care professionals providing services to Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 Reimbursement Policy — Co‑Surgeon, Team Surgeon, and Assistant Surgeon Billing

Policy CodePolicy 2025R9010B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen billing modifier 62 or 66, submit the same CPT code with the modifier and include required written documentation to support each surgeon's distinct involvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

63%co-surgeon reimbursement

NPFS 1 or 2eligible codes

No payassistant surgeon rule

Writtenteam surgeon docs

Coverage and Payment Rules

Reimbursement rules

Coverage and payment rules for co-surgeon, team surgeon, assistant surgeon interactions, and multiple procedure reductions.

Reimbursement for Co-Surgeons and Team Surgeons is subject to the eligibility of the CPT code per the CMS NPFS status indicators (1 or 2).

ALL of the following

Each Co-Surgeon must submit the same CPT code with modifier 62 for the same date of service.
For services on the Co-Surgeon Eligible List (NPFS indicators 1 or 2), UnitedHealthcare Medicare Advantage reimburses each Co-Surgeon at 63% of the Allowable Amount; 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.
Co-Surgeon reimbursement is subject to additional multiple procedure reductions where applicable.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 Reimbursement Policy — Co‑Surgeon, Team Surgeon, and Assistant Surgeon Billing

Policy CodePolicy 2025R9010B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen billing modifier 62 or 66, submit the same CPT code with the modifier and include required written documentation to support each surgeon's distinct involvement.

SourceLink

On This Page

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Relevant Codes and Rates

Surgeon-related modifiersModifier

Modifier 62	Co-Surgeon — submit same CPT with modifier 62 for eligible NPFS status indicators 1 or 2
Modifier 66	Team Surgeon — submit same CPT with modifier 66 and supporting documentation; eligible per NPFS indicators 1 or 2
Modifiers 80, 81, 82, AS	Assistant Surgeon modifiers — not reimbursed when co-surgeon reimbursement provided for same procedure

Co-Surgeon reimbursement percentage

Reimbursement percentage63% of the Allowable Amount to each co-surgeon for services on the Co-Surgeon Eligible List (subject to multiple procedure reductions)

Calculation basisAllowable Amount is determined independently for each surgeon and calculated from the Allowable Amount that would be given to that surgeon performing the surgery without a co-surgeon

Billing requirementEach co-surgeon must submit the same CPT code with modifier 62 on the same date of service

CMS basisReimbursable percentage is based on the rate adopted by CMS (allows 62.5% of allowable to each co-surgeon) though UnitedHealthcare applies 63%

Billing Requirements and Provider Responsibilities

Documentation Required

Team Surgeon documentation requirement — submit medical documentation

Modifier 66 identifies Team Surgeons involved in the care of a patient during surgery. Each Team Surgeon should submit the same CPT code with modifier 66 for the same date of service.

Each Team Surgeon must submit written medical documentation describing that surgeon's specific involvement in the total procedure when billing with modifier 66.
UnitedHealthcare will review each Team Surgeon submission along with the required documentation and make reimbursement determinations on a case-by-case basis for services on the Team Surgeon Eligible List.

Billing Rule

Co-Surgeon billing and reimbursement

Modifier 62 identifies a Co-Surgeon involved in the care of a patient at surgery. Each Co-Surgeon should submit the same CPT code with modifier 62 for the same date of service.

For services on the Co-Surgeon Eligible List, UnitedHealthcare Medicare Advantage reimburses each Co-Surgeon at 63% of the Allowable Amount, subject to applicable multiple procedure reductions.
The Allowable Amount is determined independently for each surgeon and is calculated from the Allowable Amount that would apply if that surgeon performed the surgery without a Co-Surgeon; the 63% reimbursable percentage is based on the CMS-adopted rate (approximately 62.5%).

Denial Risk

Assistant surgeon exclusion when co-surgeon paid

UnitedHealthcare Medicare Advantage follows CMS guidelines and does not reimburse Assistant Surgeon services (modifiers 80, 81, 82, or AS) for procedures where reimbursement has been provided for eligible Co-Surgeon services using the same surgical procedure code during the same encounter, Same Individual Physician or Other Qualified Health Care Professional.

If a Co-Surgeon acts as an Assistant Surgeon for additional, separate procedure(s) during the same surgical session, those procedures may be reimbursable when eligible per the NPFS Assistant Surgeon Eligibility indicator and must be billed with separate procedure code(s) and the appropriate assistant surgeon modifier (80 or 82).

Key Terms

Allowable Amount

DefinitionAllowable Amount: the 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, as applicable)

Percent/discount contractsFor percent of charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount

Role in reimbursementUsed as the basis for calculating co-surgeon and team surgeon payments (each surgeon’s Allowable Amount is determined independently)

Co-Surgeons

DefinitionCo-Surgeons: several physicians (usually with different specialties) working together as primary surgeons performing distinct part(s) of a procedure; claims are identified with modifier 62

Billing expectationEach co-surgeon should submit the same CPT code with modifier 62 for the same date of service

Distinct parts requirementCo-surgeons perform distinct parts of the procedure to be considered primary surgeons

Team Surgeons

DefinitionTeam Surgeons: three or more physicians working together during an operative session in the management of a specific surgical procedure; claims are identified with modifier 66

Billing requirementEach team surgeon should submit the same CPT code with modifier 66 and provide written documentation describing that surgeon’s specific involvement (UnitedHealthcare reviews case-by-case)

Eligibility basisTeam and co-surgeon eligible services are based on CMS NPFS status indicators (see eligible lists)

Assistant Surgeon

DefinitionAssistant Surgeon: a physician or other qualified health care professional who is assisting the physician performing a surgical procedure

Reimbursement interactionAssistant surgeon modifiers (80, 81, 82, AS) are not reimbursed when co-surgeon reimbursement has been provided for the same procedure during the same encounter (follow CMS guidelines)

Role distinctionAssistant surgeons assist the primary surgeon rather than acting as a primary co-surgeon performing distinct parts