Coding Q&A: How Does Co-surgeon Status Impact TAVI Coding and Reimbursement?
September 01, 2011
All of the transcatheter aortic valve interventions (TAVI) occurring at our facility are performed by co-surgeon teams, including a thoracic surgeon and an interventional cardiologist. How does cosurgeon status impact coding and reimbursement?
First, some background on co-surgeon status: Typically, when two physicians perform the work described by a single procedure code, both physicians append modifi er –62 (Co-surgeons) to the code on their respective claim submissions for service. This modifier communicates to the carrier that the two physicians performed the procedure in concert, on the same patient, during the same session. Under the Medicare system, this normally results in both physicians receiving fi ve-eighths of the usual reimbursement rate. If one of the operators fails to append the modifi er –62, this could result in complete non-payment for one of the physicians on the team. This is why co-operators are urged to discuss the issue of co-surgeon status prior to performing and reporting the procedure.
There is an important caveat for using modifi er –62, namely that the procedure code must be approved for co-surgeons.
Now, regarding TAVI: At this time, few interventional cardiovascular codes are eligible for co-surgeon status and, as of July 2011, the TAVI Category III code 0256T (Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach) does not support co-surgeon modifi er use. SCAI has submitted several requests to the Centers for Medicare and Medicaid Services (CMS) to correct this oversight.
Until the Medicare Physician Fee Schedule is revised to allow for co-surgeon modifi er use for code 0256T, only ONE physician may submit a claim for this code. However, because all Category III codes under the Medicare system are priced by the local carrier, a rate can be negotiated that refl ects co-surgeon involvement. This does necessitate that the co-surgeons agree on a single claim submission to the carrier by only one member of the team with the received reimbursement divided privately between the physicians.
SCAI will continue to advocate with CMS on behalf of members for fair and appropriate reimbursement for TAVI and all other transcatheter valve procedures. SCAI has been successful in such efforts in the past. For example, SCAI took the lead in securing Category III codes for transcatheter aortic and pulmonic valve procedures. In fact, SCAI has submitted a request to CMS to allow the co-surgeon modifi er with the existing Category III codes; this issue is still in development. In addition, SCAI is working on a proposal to convert the existing Category III TAVI code to a Category I code. This proposal presents co-surgeon teams as the typical scenario for performance of these procedures. Later this year SCAI members will be able to support this effort by completing RUC physician work valuation surveys. Stay tuned for details on how you can help, or contact Dawn Hopkins at firstname.lastname@example.org to volunteer.
Finally, coding, reimbursement, and CMS coverage of TAVI are separate and distinct issues. SCAI is closely monitoring developments regarding TAVI in all of these areas.
Please note: SCAI is committed to making every reasonable effort to provide accurate information regarding the use of CPT®, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. SCAI assumes no liability, legal, fi nancial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payors or Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors