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Policy No: 114

Originally Created: 09/01/2009

Section: Modifiers

Last Reviewed:  05/01/2019

Last Revised:  06/01/2018

Approved: 05/02/2019

Effective Date:  07/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 66 - Surgical Team

Current Procedural Terminology (CPT®) modifier 66 describes when three or more surgeons of same or different specialties work together as primary surgeons performing distinct part(s) of a surgical procedure.

Team Surgery

The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values which are currently in the CMS file are:

0 - Team surgeons not permitted for this procedure.

1 - Team surgeons may be paid; supporting documentation required to establish medical necessity.

2 - Team surgeons permitted.

9 - Team surgeon concept does not apply.

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)/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, 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.

Our health plan will not reimburse for an additional assistant surgeon on a procedure when reimbursement has been provided as team surgery.

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 will reimburse procedures as either co-surgery, team surgery or as surgeon-assistant.  Except for co-surgery or team surgery, only one surgeon maybe be considered the primary surgeon.  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 A - 19364 - LT

Provider B - 19364 - RT

References

Centers for Medicare & Medicaid Services (CMS), National Physician Fee Schedule Relative Value File

Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 12, Section 40.8

American Medical Association.  Appendix A:  Modifiers, Current Procedural Terminology (CPT), AMA Press.

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.