Co-Surgeon Reimbursement

Reimbursement Policy:
Co-Surgeon Reimbursement

Effective Date:
March 19, 2009

Last Revised Date:
September 1, 2016

Purpose:
Provide guidelines for the reimbursement of co-surgeons.

Scope:
All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon BCBSNJ recognizes services performed by co-surgeons and reimburses in accordance with the Centers for Medicare and Medicaid Services (CMS).

Procedure codes eligible for a co-surgeon are identified on the Medicare Physician Fee Schedule (MPFS) Relative Value File (RVF) with an indicator of 1 or 2.

Appropriate Use of Modifier 62:

  • Two surgeons, in different specialties, are required to perform a specific procedure for the patient
  • Two surgeons, in the same or different specialty, are each performing parts of the same procedure simultaneously.
  • Both physicians bill the same procedure code on the same date of service both appending modifier 62

Inappropriate Use of Modifier 62:

  • One surgeon acts as an assistant surgeon
  • Rare situations (trauma situations) where both surgeons are acting simultaneously, but not working on the same procedure
  • There are more than two primary surgeons

Procedure:
Effective September 1, 2016, claims submitted with Modifier 62 shall allow 62.5% of the applicable Horizon BCBSNJ fee schedule when appended to eligible procedure codes. Procedure codes billed with Modifier 62 are subject to additional multiple procedure reductions.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
3/19/2009: Policy approved
5/10/2016: Separated from Surgery with Modifiers policy and created as distinct policy
9/1/2016: Modifier 62 reimbursement increased from 50% to 62.5%
Policy098_v1.0_09012016