Policy Statement
Our health plan will provide reimbursement for team surgery when three or more surgeons share work and responsibility in performing a specific surgical procedure.
Team surgeons should submit the same Healthcare Common Procedure Coding System (HCPCS)/Current Procedure Terminology (CPT®) code(s) with modifier 66 appended to each HCPCS/CPT code submitted.
Our health plan considers codes with CMS Team Surgery Indicators of 1 and 2 eligible for team surgery reimbursement.
Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66.
When a provider reports an eligible procedure with modifier 66 appended, reimbursement will be 150% of the established fee schedule, divided equally between the team surgeons. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. If there is more than one procedure performed, multiple surgery guidelines apply.
If a procedure has already been reimbursed as team surgery, our health plan will not cover an assistant surgeon for it.
When a team surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery reimbursement, the appropriate assistant surgery modifier should be appended but the team surgery modifier 66 should not be used.
Our health plan reimburses procedures such as co-surgery, team surgery, or surgeon-assistant. Except for co-surgery or team surgery, only one surgeon may be considered the primary surgeon. Our health plan will not provide reimbursement when components of a procedure, separate procedures, or bilateral surgery are billed by more than a single primary surgeon. For example, our health plan will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon.
Examples of inappropriate billing
Provider A – 19364 (no modifier billed)
Provider B – 19364 (no modifier billed)
Provider C – 19364 (no modifier billed)
Provider A - 19364-LT
Provider B - 19364-RT
References
Cross References
None
