Notification Issue Date:

Policy Attachment

Attachment to Policy # 00.10.17i


Policy #:00.10.17i

Description:Team Surgery Review Form

Title:Modifier 66: Surgical Team


The attached document is the Company's Team Surgery Review Form. This form must be completed, signed, and dated by each team surgeon and submitted to the Company. Each provider must specify the percentage of the total work they performed during the team surgery. This percentage establishes the percentage of each provider's fee schedule allowance as reimbursement for that provider's participation in the team surgery.

Only one Team Surgery Review Form should be submitted to the Company. This single form must include all required information.

Please note: Submission of required information does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, and applicable provider contracts and policies apply.

To access and view the Team Surgery Review Form:
    1. Select the Adobe PDF icon below.
    2. Click the View or Open Attachment Action. The attached document is formatted as read only.

Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A

2017 AmeriHealth.