CurrentUnitedHealthcarePolicy N/A

Co-Surgeon and Team Surgeon reimbursement

Defines UnitedHealthcare Community Plan Medicaid reimbursement rules for Co-Surgeon (modifier 62) and Team Surgeon (modifier 66) services for claims submitted on CMS1500/UB04 where applicable, and describes documentation, payment percentages, eligible codes, and state exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyCo-Surgeon and Team Surgeon reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEach Co-Surgeon should submit the same CPT code with modifier 62 for the same date of service; Team Surgeons must submit written medical documentation of each surgeon's involvement for case-by-case review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

62.5%standard reimbursement rate per surgeon for Co-Surgeon services

Case-by-casereimbursement determination for Team Surgeon services with documentation

NPFS 1/2codes considered eligible for Co-Surgeon or Team Surgeon services

Multiple reductionsreductions may apply when billing multiple eligible CPT codes

Excluded

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Co-Surgeon and Team Surgeon Coverage Criteria

Co-Surgeon and Team Surgeon coverage criteria

Reimbursement rules and conditions for Co-Surgeon (62) and Team Surgeon (66) services

Co-Surgeon payment: Reimburse Co-Surgeon services at 62.5% of the Allowable Amount to each surgeon; Allowable Amount is determined independently for each surgeon and is subject to additional multiple procedure reductions if applicable.

Co-Surgeon billing: Each Co-Surgeon should submit the same Current Procedural Terminology (CPT) code with modifier 62 for the same date of service.

Team Surgeon billing and documentation

Each Team Surgeon should 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 each Team Surgeon submission with its appropriate medical documentation and make reimbursement decisions on a case-by-case basis.

Eligible codes: Codes listed in the CMS National Physician Fee Schedule (NPFS) with status indicators '1' or '2' for Co-Surgeons or Team Surgeons are considered eligible for the respective modifiers.

HCPCS crosswalk: Apply HCPCS payment indicators for G0412 - G0415 when adjudicating CPT codes 27215-27218 for purposes of this policy.

Multiple procedure reductions apply when one or more physicians bill multiple CPT codes that are eligible for reductions.

Assistant surgeon exclusion: Assistant surgeon services (modifiers 80, 81, 82, AS) are not reimbursed for procedures where Co-Surgeon reimbursement has been provided for the same surgical procedure during the same encounter; if a Co-Surgeon acts as an assistant for additional separate procedures during the same session, those additional procedures may be reimbursable when billed with separate procedure codes and appropriate assistant surgeon modifier.

Simultaneous bilateral procedures: For simultaneous bilateral procedures where each surgeon performs the same procedure on opposite sides, each surgeon should report modifiers 50 and 62; assistant surgeon services will not be reimbursed in addition.

State exceptions: State-specific exceptions may alter reimbursement percentages or coverage (examples include FL, IN, KY, MS, NM, DC, WI) as described in the policy.

Eligible Codes and Coding Notes

HCPCS/CPT crosswalk notemixed

G0412-G0415

HCPCS payment indicators applied when adjudicating CPT codes 27215-27218

NPFS eligibility — Codes with NPFS status indicators '1' or '2' for Co-Surgeons or Team Surgeons

NPFS status indicatorsCodes with NPFS Relative Value File status indicators '1' or '2' are considered eligible for Co-Surgeon (modifier 62) or Team Surgeon (modifier 66) services.

Application to listsEligible procedure codes are identified in the CMS PFS Relative Value Files using the 'CO-SURG' or 'TEAM SURG' columns.

HCPCS crosswalk noteUnitedHealthcare applies HCPCS payment indicators for G0412–G0415 when adjudicating CPT codes 27215–27218 per this policy.

Billing and Documentation Instructions

Billing Rule

Billing instruction for Co-Surgeon

Each Co-Surgeon should submit the same Current Procedural Terminology (CPT®) code with modifier 62 for the same date of service. In alignment with CMS, UnitedHealthcare Community Plan will reimburse Co-Surgeon services at 62.5% of the Allowable Amount to each surgeon, subject to multiple procedure reductions if applicable. 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.

Submit same CPT code with modifier 62 for same date of service
Reimbursement: 62.5% of Allowable Amount to each surgeon (subject to multiple procedure reductions)

Documentation Required

Documentation requirement for Team Surgeon

Key Definitions

Co-Surgeon — definition

TermCo-Surgeon

DefinitionSeveral physicians (usually with different specialties) working together as primary surgeons performing distinct part(s) of a procedure; claims submitted by Co-Surgeons are identified with modifier 62.

BillingEach Co-Surgeon should submit the same CPT code with modifier 62 for the same date of service (see billing instructions in policy).

Team Surgeon — definition

TermTeam Surgeon

DefinitionThree or more physicians (with different or same specialties) working together during an operative session in the management of a specific surgical procedure; claims submitted by Team Surgeons are identified with modifier 66.

Note

State exceptions note

State-specific reimbursement variations may alter percent paid or coverage. Examples: Florida — modifier 62 reimbursed at 50% and modifier 66 may reimburse up to 3 providers at 100% of max allowable; Indiana — certain CPT/HCPCS codes (e.g., 22586, 22861, 22862, 22864, 22865, 28890, 54400, 54408, 54410, 54411, 54416, 54417, 55400, 55870, 58974, 58976, 59866, 61630, G0276, G0341, G0342, G0343) are not covered; Kentucky — modifier 62 reimbursed at 50% of allowed amount for KY Medicaid; Mississippi — modifier 66 reimbursed at 62.5% of the Allowable Amount for MS CAN; New Mexico — total allowed value increased by 25% and each surgeon paid 50% of that amount; Washington, DC — exempt from this policy; Co-Surgeon/Team Surgeon procedures reimbursed based on the fee schedule; Wisconsin — modifier 62 reimbursed at 100% per fee schedule.

Florida: modifier 62 reimbursed at 50%; modifier 66 may reimburse up to 3 providers at 100% of max allowable
Indiana: listed CPT/HCPCS codes are not covered for Indiana (see policy for full code list)
Kentucky: modifier 62 reimbursed at 50% for KY Medicaid
Mississippi: modifier 66 reimbursed at 62.5% for MS CAN
New Mexico: total allowed value increased by 25%; each surgeon paid 50%
Washington, DC: exempt from this policy; reimbursement based on fee schedule
Wisconsin: modifier 62 reimbursed at 100% per fee schedule