Co-Surgeons (State Health Programs)
Health Net's list of procedures eligible for co-surgeon reimbursement is based in part on the Centers for Medicare and Medicaid Services (CMS) co-surgeon policy. Co-surgeon charges are not allowed for procedures denoted by CMS with the following indicators on the National Physician Fee Schedule: Indicator 0 ("co-surgeon not permitted") or indicator 9 (concept does not apply).
According to the American Medical Association (AMA) CPT definition of modifier -62, co-surgeons are two surgeons that work as primary surgeons performing distinct parts of the procedure. They each bring a different skill set to the procedure, so are not merely assisting one another.
Each surgeon must bill the same CPT code with modifier -62. When a claim is received without modifier -62 and there exists a previously processed claim for the same procedure code with modifier -62, Health Net adds modifier -62 to the second claim.
Each surgeon is reimbursed 62 percent of the allowed amount for the procedure, but is not reimbursed when billing as each other's assistant for a procedure. Multiple procedures are subject to the multiple procedure reduction rule.
If a separate surgical assistant is used, he or she must bill the same CPT code as the surgeon and reimbursement is based on 20 percent of the allowable reimbursement rate for the surgeon. Surgeons who perform additional procedures should bill separate codes without modifier -62. These codes are reimbursed at 100 percent of the allowed amount, subject to the multiple procedure reduction rule.
Surgeons may bill as assistants on each other's additional procedures only if they are not billing as primary for their own additional procedure. Surgeons may not bill as primary and assistant for the same member on the same date of service.
Health Net does not require documentation at the time of claim submission; however, in the event the claim is audited, documentation may be required.
- AMA CPT Book
- CMS National Policy