Claims for Bilateral Surgeries

40.7 - Claims for Bilateral Surgeries (Rev. 1, 10-01-03) B3-4827, B3-15040 A. General Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day. The terminology for some procedure codes includes the terms “bilateral” (e.g., code 27395; Lengthening of the hamstring tendon; multiple, bilateral.) or “unilateral or bilateral” (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as “bilateral” or “unilateral or bilateral” since the fee schedule reflects any additional work required for bilateral surgeries. Field 22 of the MFSDB indicates whether the payment adjustment rules apply to a surgical procedure. B. Billing Instructions for Bilateral Surgeries If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier “-50.” They report such procedures as a single line item. (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.) If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, physicians do not report the procedure with modifier “-50.” C. Claims Processing System Requirements A/B MACs (B) must be able to: 1. Identify bilateral surgeries by the presence on the claim form or electronic submission of the “-50” modifier or of the same code on separate lines reported once with modifier “-LT” and once with modifier “-RT”; 2. Access Field 34 or 35 of the MFSDB to determine the Medicare payment amount; 3. Access Field 22 of the MFSDB: • If Field 22 contains an indicator of “0,” “2,” or “3,” the payment adjustment rules for bilateral surgeries do not apply. Base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply. NOTE: Some codes which have a bilateral indicator of “0” in the MFSDB may be performed more than once on a given day. These are services that would never be considered bilateral and thus should not be billed with modifier “-50.” Where such a code is billed on multiple line items or with more than 1 in the units field and A/B MACs (B) have determined that the code may be reported more than once, bypass the “0” bilateral indicator and refer to the multiple surgery field for pricing; • If Field 22 contains an indicator of “1,” the standard adjustment rules apply. Base payment on the lower of the billed amount or 150 percent of the fee schedule amount (Field 34 or 35). (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.) 4. Apply the requirements §§40 - 40.4 on global surgeries to bilateral surgeries; and 5. Retain the “-50” modifier in history for any bilateral surgeries paid at the adjusted amount. (NOTE: The “-50” modifier is not retained for surgeries which are bilateral by definition such as code 27395.) 40.8. - Claims for Co-Surgeons and Team Surgeons (Rev. 3721, Issued: 02-24-17, Effective: 05-25-17, Implementation: 05-25-17) A. General Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. B. Billing Instructions The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons: • If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62.” Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (See §40.8.C.5.); • If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66.” Field 25 of the MFSDB identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.” • If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services. (See §40.6 for multiple surgery payment rules.) For co-surgeons (modifier 62), the fee schedule amount applicable to the payment for each co- surgeon is 62.5 percent of the global surgery fee schedule amount. Team surgery (modifier 66) is paid for on a “By Report” basis. C. Claims Processing System Requirements Carriers must be able to: 1. Identify a surgical procedure performed by two surgeons or a team of surgeons by the presence on the claim form or electronic submission of the “-62” or “-66” modifier; 2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery; 3. Access Field 24 or 25, as appropriate, of the MFSDB. These fields provide guidance on whether two or team surgeons are generally required for the surgical procedure; 4. If the surgery is billed with a “-62” or “-66” modifier and Field 24 or 25 contains an indicator of “0,” payment adjustment rules for two or team surgeons do not apply: • Carriers pay the first bill submitted, and base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply; • Carriers deny bills received subsequently from other physicians and use the appropriate MSN message in §§40.8.D. As these are medical necessity denials, the instructions in the Program Integrity Manual regarding denial of unassigned claims for medical necessity are applied; 5. If the surgery is billed with a “-62” modifier and Field 24 contains an indicator of “1,” suspend the claim for manual review of any documentation submitted with the claim. If the documentation supports the need for co-surgeons, base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35); 6. If the surgery is billed with a “-62” modifier and Field 24 contains an indicator of “2,” payment rules for two surgeons apply. Carriers base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35); 7. If the surgery is billed with a “-66” modifier and Field 25 contains an indicator of “1,” carriers suspend the claim for manual review. If carriers determine that team surgeons were medically necessary, each physician is paid on a “by report” basis; 8. If the surgery is billed with a “-66” modifier and Field 25 contains an indicator of “2,” carriers pay “by report”; NOTE: A Medicare fee may have been established for some surgical procedures that are billed with the “-66” modifier. In these cases, all physicians on the team must agree on the percentage of the Medicare payment amount each is to receive. If carriers receive a bill with a “-66” modifier after carriers have paid one surgeon the full Medicare payment amount (on a bill without the modifier), deny the subsequent claim. 9. Apply the rules global surgical packages to each of the physicians participating in a co- or team surgery; and 10. Retain the “-62” and “-66” modifiers in history for any co- or team surgeries. D. Beneficiary Liability on Denied Claims for Assistant, Co- surgeon and Team Surgeons When the procedure is subject to the statutory restriction against payment for assistants-at- surgery, such payment shall be denied. The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3. Group Code: CO CARC: 54 RARC: N/A MSN: 15.11 Carriers include the following statement in the MSN: "You cannot be charged for this service.” (Unnumbered add-on message.) If Field 23 of the MFSDB contains an indicator of “0” or “1” (assistant-at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary. The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3. Group Code: CO CARC: 54 RARC: N/A MSN: 15.12 For those procedures with an indicator of “0,” the limitation on liability provisions described in Chapter 30 apply to assigned claims. Therefore, carriers include the appropriate limitation of liability language from Chapter 21. For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity. Where payment may not be made for a co- or team surgeon, deny the claim The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3. Group Code: CO CARC: 54 RARC: N/A MSN: 15.13 Where payment may not be made for a two surgeons, deny the claim. The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3. Group Code: CO CARC: 54 RARC: N/A MSN: 15.12 Also see limitation of liability remittance notice Remittance Advice Remark Code Alert M27 and use when appropriate.