In a previous issue of Urology Times, this column discussed multiple procedures and the bundling edits for a single physician (“When to bill and not to bill for multiple procedures,” May 2002, page 62). This article will address multiple procedures performed at the same encounter by two separate physicians.
As stated in the earlier article, identifying all procedures performed, accurately coding the procedures, properly documenting the correct diagnosis, and then evaluating the bundling and potential global rules that apply are important and must be done prior to billing. Since the Medicare rules are well documented, we will discuss billing from the Medicare aspect, but also mention how private carriers’ rules may differ.
The decision tree on how to code is essentially the same as that discussed in the previous article. Note: To refer to the May 2002 article and decision tree, please see http://www.urologytimes.com/multiple
Questions to ask If two physicians are performing two procedures, first ask yourself the following questions:
Question 1: Is one procedure an integral part of the other?
If the answer is yes, bill only for the main procedure. The primary surgeon would charge for the surgery, and the second surgeon an assistant fee, even if the second surgeon performed part of the surgery.
If the answer is no, then ask yourself:
Question 2: Does a single CPT code cover both procedures?
If the answer to this question is no, then each surgeon should bill for his or her procedure, and no modifier is needed. In addition, each could bill an assistant’s fee if one surgeon assisted the other and the rules allow for an assistant’s fee.
If the answer to question 2 is yes, then the single CPT code must be used. Then ask:
Question 3: Is it possible to use the -62 modifier as determined by the Medicare rules?
If the answer is yes, each surgeon would bill the code using modifier ?62. If the answer is no, the surgeon performing the most extensive procedure would charge for the procedure, and the other surgeon would have to charge an assistant’s fee.
The bundling edits should not apply to two physicians of two separate specialties and skills providing two separate procedures. However, all payers may not adhere to this concept. Let’s work through some examples to show exactly how to code.
Example 1.
A urologist and a gynecologist both perform surgery on a female patient. The urologist performs a sling procedure (57288), and the gynecologist performs a posterior repair (57250).
Looking at the CPT book, the sling and the posterior repair are two separate procedures. There is no one CPT code that would define each. Therefore, the urologist would charge for the 57288 (sling procedure), and the gynecologist would charge for the 52250 (posterior repair), with no modifiers needed. If each assisted the other, then each would charge for an assistant’s fee on the other procedure, as follows:
Urologist: 57288, 57250-80
Gynecologist: 57250, 57288-80
Example 2.
A urologist performs an anterior repair on a patient (57240), and a gynecologist does a posterior repair (57250). The CPT book indicates that there is one code, 57260, that explains both procedures. Therefore, we cannot charge separately for the anterior repair (57240) and the posterior repair (57250) but must use the comprehensive code (57260).
The appropriate way to charge would be to use the ?62 modifier and provide documentation. Each surgeon would charge 57260-62 and send in a copy of his or her operative report indicating that the urologist performed the anterior repair and the gynecologist performed the posterior repair. In summary, the coding would be:
Urologist: 57260-62
Gynecologist: 57260-62
Example 3.
A urologist performs a sling procedure (57288) and an anterior repair (57240), and the gynecologist performs a posterior repair (57250). It would seem that the simplest way to charge would be for the urologist to charge for the sling and the anterior repair and the gynecologist to charge for the posterior repair. However, since one CPT code describes both the anterior and posterior repair, it would be inappropriate to charge the two procedures separately, even though two different physicians performed them.
Therefore, the appropriate solution would be for the urologist to charge for the 57288 and the gynecologist to charge for an assist. Then the urologist and the gynecologist would both charge the 57260?62. In summary, coding would be as follows:
Urologist: 57288, 57260-62
Gynecologist: 57260-62, 57288-80
Example 4.
The urologist performs a sling procedure (57288), and the gynecologist performs an enterocele repair (57268). The urologist should charge the 57288, and the gynecologist should charge the 57268. Again, if each assisted the other, an assistant’s fee should be charged.
I chose this particular example because you may encounter a problem with payment. In the bundling edits, the 57268 is bundled into the 57288 and can never be unbundled. Some payers may use this as an argument not to pay. However, documentation showing that two separate physicians were involved and an explanation that the bundling edits only apply to a single physician should be adequate to achieve payment. Medicare probably would not pay an assistants fee on a bundled service. In summary, coding for this final example would be:
Urologist: 57288
Gynecologist: 57268
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
