Effective Date: October 14, 2019

Purpose:
Provide guidelines for the application of modifier -66 when appropriately billed by professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier 66: Used to identify when three (3) or more surgeons of same or different specialties work together as primary surgeons performing distinct part(s) of a surgical procedure.

Policy:
Horizon NJ Health shall consider for reimbursement procedures appended with modifier -66 only in instances where the procedure or service permits team surgery per the CMS.

Determination of whether team surgery is billable is based on the Team Surgery column from the current CMS National Physician Fee Schedule Relative Value Guide as follows:

• 0 = Team surgeons not permitted for this procedure,
• 1 = Team surgeons may be paid; supporting documentation required
• 2 = Team surgeons permitted
• 9 = Team surgeon concept does not apply

Procedure:
Horizon NJ Health shall deny procedures appended with modifier -66 when the procedure or service has an indicator of “0” or “9” in the CMS National Physician Fee Schedule Relative Value Guide. Additionally, if the procedure is not deemed appropriate for team surgery, the service will be denied.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, Section 40.8 cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Centers for Medicare & Medicaid Services (CMS), National Physician Fee Schedule Relative Value File cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services