A licensed professional who effectively helps the operating surgeon during a surgical operation is called an “assistant surgeon.” Practices potentially lose insurance reimbursement by inappropriate billing of surgical assistants. The most common reason for claim denials in such situations is the use of the incorrect modifier or the failure to use the modifier. Billing success depends on how doctors document operative reports and use modifiers. “Assistant at surgery” is a billable service, and Medicare pays 16% of the standard surgical allowance for it. Outsourcing medical billing and coding relieve busy surgeons from the burden of claim documentation and submission.
Billing For Assistant Surgeon
An assistant surgeon must be board-certified, professionally competent as a skilled surgeon, and licensed as a physician in the state where the services are being provided. Primary surgeon services will be reimbursed at 100% of the optimum allowance for the primary surgery. If requirements for assistant surgeon services are met, the assistant surgeon will be eligible for an increase of 11 percent. We have tried to cover every aspect of surgical assistant billing in this article, including defining surgical assistants, billing guidelines, reimbursement policies, and the correct use of modifiers.
The primary surgeon is billed on a single claim, while the assistant surgeon is billed on a different claim in their name. One of the following modifiers should be included in the assistant surgeon claim:
Modifier 80 — Assistant Surgeon:
This modifier applies only to physician services. A physician’s surgical assistant services can be identified by appending the modifier 80 to the surgical operation code. This modifier refers to an assistant surgeon who assists the primary surgeon entirely and is not designed to be used by non-physician providers.
Modifier 81 — Assistant Surgeon:
This modifier applies only to physician services. By appending the modifier 81 to the surgical procedure code, you can identify an assistant surgeon who provides minimal assistance to the primary surgeon. Non-physician providers should not use this modifier. This modifier is commonly used in private insurance but not in Medicare billing.
Modifier 82 — Assistant Surgeon:
This modifier is only for physician services. The service must have been performed in a teaching facility and conducted in the absence of a qualified resident surgeon. The reason a resident surgeon was unavailable must be recorded in the health record. Non-physician providers should not use this modifier.
Medicare does not reimburse Registered Nurse First Assistants (RNFAs) for assistant-at-surgery services. Still, it does reimburse Advanced Registered Nurse Practitioners (ARNP), Clinical Nurse Specialists (CNS), and Physician Assistants (PA) if the service falls within their state scope of practice, protocol, and hospital-granted benefits.
Payment Policy Indicators And Documentation Requirements
The payment policy indicator used by Medicare determines whether or not an assistant-at-surgery will be reimbursed. Following are the indicators:
Medicare may pay for an assistant-at-surgery if medical record documentation facilitates the assistant’s medical necessity. Providers should record the patient and procedure properties that necessitate the assistance of an assistant surgeon in this section.
The assistant-at-surgery may not be paid because this procedure is subject to legal payment restrictions. If the chart notes have demanded a review, that data should be documented for this indicator assigned procedures, in addition to documenting why an assistant is necessary for the surgery.
Physicians should know that this service cannot be billed to the patient. It is not suggested to request that the patient sign an Advanced Beneficiary Notice (ABN) to transfer financial liability from the provider to the patient. Even if you are denied, it is doubtful that your denial will be reversed on appeal, whatever the level of appeal.
Even though payment restrictions for services do not impose on this process, the assistant-at-surgery may be paid for it.
No concept applies (the most likely explanation is that the procedure is not surgery).
For these services to be funded, surgeons must recognize to include in the body of the operative note what the assistant surgeon made a significant contribution to the surgery.
Billing Guidelines For Team Surgeons
Extremely complex procedures require various physicians of different specialties, as well as other highly skilled equipment and personnel may be recognized for reimbursement as team surgery. Assistant surgeons are only reimbursed for 16% of the procedure’s maximum allowance. If the above-mentioned criteria are not met, services will not be reimbursed. Minor, non-surgical processes that do not involve extensive physicians from various specialties and highly skilled personnel and equipment will be denied if submitted with modifier 66.
Billing Guidelines For Co-Surgeons
Co-Surgeons are two or more surgeons whose skills are required to perform distinct elements of a particular surgical procedure. Co-surgery is always done at the same time as the main operation session. The procedure was divided equally between the co-surgeons. Services provided by surgeons of various specialties or subspecialties, each distinct performing component of a surgical procedure as primary surgeons, will be allowed at 120% of the primary procedure allowance. If additional operations are carried out, multiple procedure guidelines may apply. Each surgeon’s unique operative work should be documented in a separate operative report. Claims from both co-surgeons should be considered.
Document the same procedure code as before, but with modifier 62 appended. The total operative session allowance will be shared evenly among the co-surgeons. Co-surgeon claims for procedures will be denied when both surgeons have the same specialty or subspecialty. When a non-surgical process claim is submitted with modifier 62 for a co-surgeon, the claim will be rejected because the concept of a co-surgeon does not impose.
Reimbursement For Surgical Assistants
We used CMS and the American College of Surgeons standards to describe the reimbursement for Surgical Assistants. Co-surgeons are reimbursed at 120 percent of the optimum allowance for the primary procedure. Assistant surgeons are reimbursed at 16% of the procedure’s optimum allowance. Specific considerations will be used to determine reimbursement for group surgery. When the medical necessity and applicability of assistant surgeon services are fulfilled, and the physician assistant/nurse practitioner/nurse midwife is under the specific supervision of a doctor, reimbursement for physician assistant/nurse practitioner/nurse midwife services may be permitted. The hospital-employed doctor assistant/nurse practitioner/nurse midwife will not be reimbursed separately. The reimbursement in case of covered procedure for a physician assistant/nurse practitioner/nurse midwife is 13.6 percent of the maximum.
A professional medical billing provider can assist providers in submitting precise and timely claims for the tests performed with accurate and complete medical documentation. We are a professional medical billing company that provides comprehensive medical billing and coding services and evaluates payer billing regulations and reimbursement policies to bill surgical assistants accurately. For any assistance in billing and coding for surgical services, please email us at firstname.lastname@example.org or call us at 866-886-6130.