With a Little Help from My Friends: Tips for Coding Common Pediatric Orthopaedic Procedures with Co‐Surgeons and Assistant Surgeons

Introduction

Most pediatric orthopaedic practitioners have experienced operative cases, either in training or in practice, where the complexity and need to provide appropriate quality care mandate the presence of more than 1 surgeon. Multiple studies assessing the use of 2 attending surgeons for spinal deformity surgery for adolescent idiopathic scoliosis have concluded that this approach decreases blood loss, operative time, blood transfusions, and postoperative complications [1], [2], [3], [4], [5], [6], [7], [8]. Similar results have been found for adult spinal deformity surgery [9], [10] and cases involving pedicle subtraction osteotomies [11], congenital scoliosis [12], and neuromuscular scoliosis [13], [14], [15], [16]. Having a more experienced surgeon available may also benefit younger spine surgeons [7] and lower-volume spine surgeons [17]. Subspecialties other than spine surgery are less studied but would likely show similar results. For example, single event multilevel surgery (SEMLS) for cerebral palsy and complex limb deformity corrections might be more efficient and have improved outcomes with more than 1 experienced surgeon participating.

Though most surgeons agree that having 2 experienced practitioners participate in complex cases benefits patients, one of the barriers to implementing this strategy is a concern about physician reimbursement [9], [4]. To consider a 2-surgeon strategy and remain compliant, it is important to understand physician reimbursement policy, the use of appropriate modifiers to Current Procedural Terminology (CPT) codes, and how total reimbursement and Relative Value Units (RVUs) are affected by the presence of multiple surgeons. Because policies and reimbursements are different based on the type of work that a second surgeon does, it is critical to understand when surgeons are considered assistants and when they are considered co‐surgeons.

Current policy

The American Medical Association (AMA) maintains and edits the CPT manual. The AMA/Specialty Society Relative Value Scale Update Committee proposes relative value unit values to CPT codes, as well as recommendations regarding medical billing and coding to the Centers for Medicare and Medicaid Services (CMS). CMS and other third-party payers often (but not always) use the AMA’s recommendations as their official policy regarding physician reimbursement. The AMA has provided several modifiers to CPT codes for use when multiple surgeons are present to perform the same surgical procedure. Unfortunately, policy from CMS does not always match guidance from the AMA, so using modifiers appropriately can still lead to confusion and denials of reimbursement.

62. Two surgeons

When 2 surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report their distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes for that procedure as long as both surgeons continue to work together as primary surgeons [18]. According to CMS, this situation is usually when 2 surgeons from different specialties are required to perform a specific procedure. Due to the complexity of the patient’s condition or the procedure(s) required, 2 surgeons from the same specialty might also be considered co-surgeons if they perform distinct parts of a procedure simultaneously, but there are very few pediatric orthopaedic examples that qualify.

When a procedure is eligible for co-surgeons, both surgeons have responsibility for preoperative and postoperative services, and both must generate an operative report describing their distinct portion of the procedure. It is imperative to include documentation in each operative report to support the medical necessity of 2 surgeons. Both surgeons should report the same ICD-10 diagnosis code(s) and the same CPT code(s) with modifier 62 [19]. CMS reimburses each surgeon 62.5% of the original fee (125% total) for 2 surgeons [18].

Note that if 2 surgeons each perform a different procedure with specific CPT codes, neither co-surgery nor multiple surgery rules apply [18]. An example might include a multitrauma patient where one orthopaedic surgeon performs open reduction with internal fixation for a shoulder fracture and another performs open reduction with internal fixation for an ankle fracture under the same anesthetic. Another example might include a neurosurgeon performing a spine osteotomy separately from an orthopaedic surgeon performing a Posterior Spine Fusion (PSF) with instrumentation, even though, in this case, both surgeons from different specialties perform the procedures through the same incision [20].

66. Surgical team

There is a very high bar for surgeries that are eligible for a team of surgeons compared to assistant surgeons or co-surgeons. The 66 modifier was created by the AMA to address complex procedures requiring teams of surgeons (3 or more) from different specialties (eg, solid organ transplant procedures or the separation of conjoined twins). There are very few orthopaedic procedures that are eligible for the 66 modifier [18]. For example, routine PSF codes (22800-22804) and codes used in SEMLS surgery are ineligible [21]. Some of the complex vertebrectomy and kyphectomy codes (22818, 22819, 63081-63091) may be eligible for modifier 66, but even in these cases, each member of the surgical team comprising different specialties would have to dictate a separate operative report with a section explaining the necessity of multiple surgeons. Even if eligible, pricing for services with modifier 66 is done on an individual basis, requiring negotiation with the payer to establish appropriate rates [18].

80. Assistant surgeon

81. Minimum assistant surgeon

82. Assistant surgeon (when qualified resident surgeon not available)

AS Assistant at surgery advanced practice provider

Modifiers 80, 81, and 82 are used when one surgeon of the same or a different specialty, assists another surgeon. Modifier AS is used when an advanced practice provider assists a surgeon. For example, a physician assistant or nurse practitioner “provide an extra set of hands,” but do not perform procedures independently [22]. Assistants do not have responsibility for evaluating patients preoperatively or postoperatively and do not need to generate a separate operative report [19]. Not all procedures qualify for reimbursement for an assistant. When procedures are eligible for an assistant surgeon, the primary surgeon should clearly document in the operative report the need for an assistant and their role during the procedure [19]. At teaching institutions, modifier 82 should be used, and the primary surgeon should also include a section in the operative report noting that a qualified resident surgeon is not available.

Medicare does not reimburse assistant services for procedures where an assistant is used in fewer than 5% of cases performed in the United States [23]. Most payers follow Medicare policy and reimburse an additional 16% for assistant surgeons (a total of 116%). For modifier AS, Medicare payments to advanced practice providers are reduced by 15% for all services (reducing the extra 16% in this situation to 13.6%) [23].

Eligibility for assistant surgeon, 2 surgeons, and surgical team modifiers

Not all procedures qualify for assistant surgeons, co-surgeons, or a team of surgeons. CMS provides guidance regarding which CPT codes may be eligible for these modifiers by assigning “indicators,” which can be found in the Medicare Physician Fee Schedule Database (MPFSD) [21]. CMS publishes the MPFSD online and provides an online search tool to find indicators for every CPT code [24]. Go to https://www.cms.gov/medicare/physician-fee-schedule/search. Under “Year,” select the latest version. Select “All” for the type of information. To search up to 5 codes at once, choose “List of Healthcare Common Procedure Coding System Codes” under Healthcare Common Procedure Coding System Criteria, and enter the 5-digit CPT code numbers. Under Modifiers choose “All Modifiers,” and under Medicare Administrative Contractor Option, choose “National Payment Amount.” This will return detailed data for each code. Scroll to the right, and you will find columns that list indicators denoting whether the procedure is eligible for modifiers for multiple surgeries, bilateral surgeries, assistant surgeons, co-surgeons, and a team of surgeons (Fig. 1).

Figure 1.

Screenshot of the online search tool of the Medicare Physician Fee Schedule Database; https://www.cms.gov/medicare/physician-fee-schedule/search. RVU, relative value unit.

The indicators used differ for modifiers 80, 81, and 82 versus modifiers 62 and 66 [20]. For the assistant surgeon modifiers, an indicator of “0” means that a “payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.” An indicator of “1” means that there is a “statutory payment restriction for assistants at surgery applying to this procedure. Assistant surgery may not be paid.” An indicator of “2” means that a “payment restriction for assistants at surgery does not apply to this procedure. Assistant surgery may be paid.” And an indicator of “9” means that the “concept does not apply.”

For co-surgeons and a team of surgeons, CMS designates procedures that are eligible for payment with a “2” indicator in the MPFSD [21]. CPT codes with indicators of “1” might be eligible for payment, based on the documentation, but may trigger a manual review by the payer. CPT codes with indicators of “0” are not eligible for payment. CPT codes with an indicator of “9” means that the concept does not apply. Not that for modifiers 62, 66, 80, 81, and 82, an indicator of “2” means that payment is likely allowed (Table 1).

Table 1.

Medicare Physician Fee Schedule Database indicators based on modifier.

	Ineligible for payment	Eligible only with supporting documentation	Eligible for payment	Concept does not apply
62, 66	0	1	2	9
80, 81, 82	1	0	2	9

Coding scenarios

A general surgeon provides access for exposure and closure for a vertebral body tethering (VBT) procedure, either thoracoscopically for a thoracic curve or through a retroperitoneal approach for a lumbar or thoracolumbar curve.

Anterior thoracic VBT uses codes 22836 or 22837, depending on the number of segments involved, or 22838 for a revision VBT procedure. The AMA CPT Manual specifically states, “When two surgeons work together as primary surgeons performing distinct part(s) of the thoracic vertebral body tethering, each surgeon should report his or her distinct operative work by appending modifier 62 to the procedure code. Modifier 62 may be appended to procedure code(s) 22836, 22837, 22838, as long as both surgeons continue to work together as primary surgeons.” [25].

Accordingly, this statement from the AMA means that VBT surgery is currently the most common pediatric orthopaedic example where the use of modifier 62 is clearly appropriate. All 3 codes have a “2” indicator for co‐surgeons, so it is most appropriate for both the spine surgeon and the general surgeon to use the same International Classification of Diseases codes and to bill the appropriate VBT code with a 62 modifier. Both should dictate operative reports separately and include language describing the necessity for co‐surgeons. Codes 22836, 22837, and 22838 all have a “0” indicator for an assistant surgeon [21].

Lumbar/thoracolumbar VBT still uses the category III codes 0656T and 0657T. Category III codes are meant to describe newer experimental procedures and have no assigned work Relative Value Unit values. There are no indicator designations for category III codes. When requesting payment for category III codes, rates for all surgeons involved must be negotiated with payers on an individual basis.

Two surgeons help each other doing a PSF with instrumentation for scoliosis. Each does roughly the same aspects of the procedure on their side of the spine.

A posterior arthrodesis is typically coded with 22802 to 22804, depending on the number of segments involved. Posterior spinal instrumentation is typically coded with 22843 to 22844. The AMA and CMS provide somewhat contradictory information regarding the use of modifiers for 2 surgeons for these procedures. The one constant between them both is that modifier 62 requires 2 surgeons working together as primary surgeons performing distinct parts of a procedure.

For the arthrodesis codes, the AMA CPT Manual states, “…when two surgeons work together as primary surgeons performing distinct part(s) of an arthrodesis for spinal deformity, each surgeon should report his or her distinct operative work by appending modifier 62 to the procedure code. In this situation, modifier 62 may be appended to procedure code(s) 22800-22819 as long as both surgeons continue to work together as primary surgeons.” But for the instrumentation codes, the same section of the AMA CPT Manual states, “Do not append modifier 62 to spinal instrumentation codes 22840-22848, 22850, 22852, 22853, 22854, 22859.” [25].

In contrast to the advice from the AMA, CMS designates the arthrodesis codes with a “1” indicator for modifier 62, making the bar to reimbursement high, while designating the instrumentation codes with a “2” indicator for modifier 62. However, the one constant between the AMA and CMS for this situation is that modifier 62 requires 2 surgeons working together as primary surgeons performing distinct parts of a procedure. Even if surgeons were to contemplate the use of modifier 62 for spine surgery, they would have to document the complex nature of the procedure or the patient’s condition and what unique skills are required from each surgeon for justification. This would likely result in denials of modifier 62 from many payers for most cases.

There are no barriers to using the assistant surgeon modifiers, 80 or 82, for the arthrodesis and instrumentation codes. Two surgeons helping each other on a routine PSF with instrumentation would be considered a primary surgeon and an assistant-at-surgery. This is likely the most reliable method to ensure appropriate reimbursement. This would apply whether the 2 surgeons are from the same specialty or different specialties and would apply regardless of the patient’s type of scoliosis or underlying comorbidities.

Two surgeons perform different aspects of a complex spine surgery. Surgeon A performs PSF and instrumentation, and surgeon B performs a 3-column osteotomy.

The same codes mentioned above are used for PSF and instrumentation. Three-column osteotomies are typically codes with 22206 to 22208. In this scenario, surgeon A and surgeon B would dictate individual operative notes and bill for the specific procedures they performed. No co‐surgeon or assistant surgeon modifier would apply. This scenario is likely the most reliable for receiving reimbursement, whether the 2 surgeons are from the same specialty or different specialties.

Two orthopaedic surgeons perform a bilateral SEMLS procedure. Each does the same procedure on opposite sides.

SEMLS can involve many different codes, as the treatment is typically individualized to the patient. Examples might include varus derotational osteotomies (27165), femoral derotational osteotomies (27450), tenotomies for hip contractures (27000-27005), tenotomies or lengthenings for knee flexion contractures (27306-27307, 27390-27395), gastrocnemius or Achilles tendon lengthenings (27606, 27687), and various foot procedures (27680-27686, 27690-27692, 28300).

While each SEMLS procedure is patient-specific, research shows better patient outcomes when multiple procedures are performed under the same anesthesia session [26]. Each surgeon would dictate their own operative note describing the individual procedures performed and the medical necessity required to support both surgeons. Any unilateral procedures would be reported by the specific surgeon.

The following 2 CPT codes pose the biggest challenge for SEMLS as the CPT nomenclature includes “bilateral.” Just as it would not be appropriate to use the bilateral 50 modifier, it would also not be appropriate for each surgeon to code the unilateral CPT code when a bilateral CPT code exists. If these procedures are included in the SEMLS procedure, 1 surgeon should be the primary surgeon, and 1 should be the assistant surgeon or cosurgeon. Both CPT codes have a “1” indicator for cosurgery billing. Therefore, medical necessity for cosurgery must be documented and supported, and a higher bar exists for reimbursement.

27392 (Tenotomy, open, hamstring; knee to hip; multiple tendons, bilateral).

27395 (Lengthening of hamstring tendon; multiple tendons, bilateral).

A senior surgeon helps a junior surgeon with a complex case (eg, a reconstruction for developmental dysplasia of the hip).

Whether a senior surgeon who is helping a junior surgeon with a case can be considered an assistant or co‐surgeon, and use the appropriate modifier, depends on the competence of the junior surgeon. When a senior surgeon is mentoring a junior surgeon on an index procedure or a more complex procedure, this does not qualify for a co‐surgery or an assistant surgery scenario, as the junior surgeon is effectively still being trained. A senior surgeon who provides assistance while guiding a junior surgeon through a case is not sufficient to justify a co‐surgeon or assistant surgeon modifier.

Once the junior surgeon is capable of performing the surgery independently, then co‐surgery or assistant surgery may qualify. Because few pediatric orthopaedic procedures qualify for co‐surgeons, the most likely scenario is that they would then be considered an assistant. Common codes for developmental dysplasia of the hip reconstruction may include 27147, 27156, 27258, and 27259. All have a “2” indicator for an assistant surgeon, but none have a “2” indicator for a co‐surgeon [21].

Are there any orthopaedic procedures that allow a team of surgeons with modifier 66?

As noted above, there are very few procedures in the musculoskeletal section of CPT that have a “2” indicator for a team of surgeons, and all are complex spine procedures. As mentioned above, the VBT codes, 22836, 22837, and 22838 have a “1” indicator for a team of surgeons, so appropriate documentation of the necessity of each team member from a different specialty and their unique role might influence some payers. But, from a practical standpoint, it is likely difficult to justify a team of surgeons for pediatric orthopaedic procedures, and obtaining reimbursement may be difficult.

Summary

Teaming up with a colleague is a proven way to enhance efficiency, safety, and outcomes for our pediatric orthopaedic surgery patients. CMS has created specific modifiers to CPT codes that guide reimbursement scenarios with more than 1 surgeon: 62 modifier, 66 modifier, 80/81/82/AS modifier.

• •The 62 modifier is best used in a scenario where 2 surgeons from different specialties are performing 2 separate procedures through the same incision, for example, VBT. Both surgeons would be required to dictate an operative report. The CPT codes would be reimbursed at 125% when the 62 modifier is attached.
• •The 66 modifier is used when a team of surgeons is required to complete an operation. This is meant for complex cases like solid organ transplants and is not typically utilized in pediatric orthopaedics.
• •The 80/81/82 modifiers are most applicable in pediatric orthopaedic scenarios when one partner helps another perform surgery. A single operative report is required with a specific paragraph detailing the necessity of the second surgeon (eg, complexity of case, saving time, blood loss, enhancing outcome). The CPT codes would reimburse at 116% when the 80 or 82 modifier is attached.

Using the MPFSD (https://www.cms.gov/medicare/physician-fee-schedule/search) is an advanced way to determine if the surgery you are planning with a teammate qualifies for any of these modifiers. The appropriate use of the modifier and corresponding documentation, when supported by AMA and CMS guidelines, typically allows compliance and commensurate reimbursement.

Author contributions

All four authors contributed with idea formation, manuscript creation, and editing.

Declarations of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.