Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule

§9789.16.7. Surgery - Co-Surgeons and Team Surgeons.

(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/Determination of Maximum Payment

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:

(1) 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 Co-Surgeons (“Co Surg”) column of the National Physician Fee Schedule Relative Value File. If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “1,” any documentation submitted with the claim should be reviewed to identify support for the need for co-surgeons. 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. If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “2,” payment rules for two surgeons apply. The claims administrator shall base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount. If the surgery is billed with a “-62” modifier and the Co-Surgeons column contains an indicator of “0,” payment for co-surgeons is not allowed.

(2) 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.” The Team Surgery (“Team Surg”) column of the National Physician Fee Schedule Relative Value File identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary.

If the surgery is billed with a “-66” modifier and the Team Surgery column contains an indicator of “1,” the claim should be reviewed to identify support for the need for a team of surgeons. If the claims administrator determines that team surgeons were medically necessary, each physician is paid on a “by report” basis.

If the surgery is billed with a “-66” modifier and the Team Surgery column contains an indicator of “2,” the claims administrator shall pay “by report”.

All claims for team surgeons must contain sufficient information to allow pricing “by report.”

(3) 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.

(4) 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.

NOTE: A 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 payment amount each is to receive. If the claims administrator receives a bill with a “-66” modifier after the claims administrator has paid one surgeon the full payment amount (on a bill without the modifier), deny the subsequent claim.

(5) Apply the rules relating to global surgical packages to each of the physicians participating in a co- or team surgery.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

HISTORY

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).

2. Amendment of subsection (b)(1) filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2018, No. 45).