Professional Surgery Guidelines

Assistant Surgery 

CPT codes with an indicator of 2 allow an assistant. CPT codes with indicators 0, 1 or 9 in the assistant surgery column do not allow payment for an assistant surgeon. If the CMS indicator is 0 and the service is denied, you may submit an appeal along with the appropriate medical record documentation and the claim will be reviewed. Please refer to the CMS Physician Fee Schedule for assistant surgeon indicators.

Assistant Surgeon Modifiers

Blue Cross and Blue Shield of Nebraska (BCBSNE) follows CMS guidelines on the use of assistant surgeon modifiers.

Assistant or Multiple Assistants During Surgery

The use of more than one assistant surgeon is subject to individual consideration and covered only upon substantiation of medical necessity. Participating physicians agree to accept the BCBSNE medical director’s decision in such cases.      

Bilateral Surgeries: Modifier 50 

Bilateral surgeries should be reported on one line with modifier 50 and one unit. 

Co-Surgery: Modifier 62

Under certain circumstances, the skills of two surgeons (with different skills) may be required in the management of a specific surgical procedure:

• The procedure, when performed by co-surgeons, requires that modifier 62 be appended on both claims. A surgeon cannot be a co-surgeon and an assistant surgeon during the same operative session; they can only bill for co-surgery or assistant surgery.
• Both surgeons will be reimbursed 62.5% of the allowable amount.
• Skills (specialty/taxonomy) of different surgeons are required for reimbursement of co-surgery.

Global Surgery

BCBSNE follows global surgery as defined by CMS. The global surgery period can be found on the CMS Physician Fee Schedule.

Major Surgical Procedures

Major surgical procedures have a 90-day global period.

Minor Surgical Procedures

Minor surgical procedures have a zero-to-10-day global period.

Multiple Surgeries – Not ASC

Dates of service prior to Dec. 1, 2021: When a surgeon performs multiple surgical procedures on a patient during one surgery, BCBSNE reimburses the physician for the procedures based on Relative Value Unit (RVU).

We reimburse providers:

• 100% of the allowable amount for the procedure with the highest RVU 
• 50% of the allowable amount for the procedure with the next highest RVU  
• 25% of the allowable amounts for the third, fourth and fifth procedures in descending order of RVU

All additional procedures will be denied as content to the other procedures. 
   
Effective for dates of service Dec. 1, 2021, and after: There will no longer be a 0% reimbursement for more than five surgeries that are subject to multiple surgery cutback. Instead, those services (subject to multiple surgery cutback) will be reimbursed at 25% of the allowable amount for more than five surgeries with no limit applied.

Postoperative Care Only

If a provider other than the surgeon manages postoperative care only, their claim must be billed with the surgical procedure code, modifier 55 and the date of surgery as the date of service.

Reimbursement for the postoperative care only (modifier 55) will be at the lesser of the charge or 10% of the contracted rate of the surgical procedure.

Surgical Care Only

Use the surgical CPT code with modifier 54 to report surgical care only. BCBSNE will reimburse the lesser of the charge or 90% of the contracted rate to the surgeon for surgical care only. The date of service is the date of surgery.

Surgical Standby/Physician Attendance

Attendance/standby services are not covered. If a physician performs a service, the specific CPT code that describes the service should be billed.

Surgical Team

Modifier 66, a highly complex procedure requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment (e.g., patient requiring surgical correction of an ankle fracture by an orthopedic surgeon, treatment of a head injury by a neurosurgeon and complex laceration repair by a plastic surgeon all operating in the same surgical suite), is described with modifier 66:

• Each physician’s claim should be submitted with modifier 66 indicating team surgery.
• Because each surgeon is operating independently, benefits are determined as if they were separate operative sessions.