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1 dic, 2018

Correct coding for assistant surgeons

BCBSRI follows CMS guidelines on assistant-at-surgery services that are reimbursable; however, BCBSRI will only reimburse for an assistant surgeon for services with a Medicare Physician Fee Schedule indicator of 2 (assistant surgeon may be paid). Providers may not require members to pay for an assistant surgeon (indicator 0, 1 or 9), even if the members accept responsibility to do so, as this is charging outside of the allowed amount.

An assistant-at-surgery actively assists the primary surgeon and participates in the performance of a procedure. The operative report should contain the specific service(s) the assistant surgeon rendered. Multiple procedure codes may be billed for a surgical session but only some of the codes may be eligible for assistant surgeon reimbursement. Reimbursement is determined by the procedure code indicators found on the Medicare Physician Fee Schedule (MPFSD).

MPFSD Indicators
Definition
0
The assistant surgeon may be paid with documentation to support medical necessity however, BCBSRI does not perform medical necessity reviews for an assistant surgeon.
1
The assistant surgeon may not be paid.
2
The assistant surgeon may be paid.
9
Not applicable concept (e.g., service is not surgery).

 

Modifier
Description
Role
80
Assistant Surgeon
Provides full assistance to the primary surgeon and capable of taking over the surgery should the primary surgeon become incapacitated.
81
Minimum Assistant Surgeon
An assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon.
82
Assistant Surgeon (when qualified resident surgeon not available)
Used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable.
AS
Physician assistant, nurse practitioner, clinical nurse specialist, or *Registered Nurse First Assistant for an assistant at surgery.
A mid-level provider provides full assistance to the primary surgeon.

 

During a recent claim review, we found inconsistencies with assistant-at-surgery billing. Therefore, we would like to remind providers of important claim submission guidelines to ensure correct claim processing.

  • When an assistant surgeon claim is filed, there must also be a primary surgeon claim for the reported services.
  • The assistant surgeon should use the appropriate modifier to identify assistant surgery services on every claim line.
  • Assistant surgery claims should not be split billed. All services should be billed on a single claim by the assistant surgeon.

*There is no Medicare provider category for RNFAs; however, BCBSRI does reimburse RNFAs for assistant-at-surgery services based on the MPFSD indicator

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