When co-surgeries and assistant surgeries are performed, it is very important that it is documented correctly so the appropriate modifiers can be added. Also, not all CPT codes can be billed as a co-surgery or an assistant surgery. Observing does not qualify as a co-surgery or an assistant surgery.
Co-surgery
For a co-surgery, both surgeons must be of a different specialty and each surgeon must write their own operative note reflecting what part of the procedure they performed. The same CPT code(s) will be billed for both surgeons with a 62 modifier added.
Billing Example:
Primary surgeon-45126-62
Co-surgeon-45126-62
CPT modifier definition for 62 modifier (Two Surgeons)
When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added.
Assistant Surgery
For an assistant surgery, the primary surgeon will write the one and only operative note, and they must document in the note that the faculty member assisting them (who may be from the same specialty) was first assist because no qualified resident was available. The same CPT code(s) will be billed for both surgeons, however, the primary surgeon will have no modifier added and the assistant surgeon will have an 82 modifier added.
Billing Example:
Primary surgeon-47562
Assistant surgeon-47562-82
CPT definition for 82 modifier (Assistant Surgeon (when qualified resident surgeon not available))
The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
Resource: CPT 2025 Professional Edition
Revenue Cycle Financial Clearance working in conjunction with Coding Education to bring you information to manage the patient experience for all patients at UTMB. We are dedicated to the education and success of all UTMB providers. Please contact The RCO Financial Clearance and Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |