Assistant Surgeon Reimbursement Policy

Assistant Surgeon Reimbursement Policy


EmblemHealth provides coverage for assistant surgeons for many procedures. An assistant surgeon is considered medically necessary when the complexity of the operation necessitates the primary surgeon have additional skilled operative assistance from any of the following: 1. Another surgeon. 2. A licensed physician assistant 3. A registered nurse first assistant. The Centers for Medicare and Medicaid Services (CMS), as outlined in the Physician Fee Schedule Database, has developed an assistant surgeon reimbursement policy. CMS has designated surgical procedures as follows: 1. Those where an assistant at surgery may be paid (Indicator “2”). 2. Those where documentation must be submitted to substantiate the medical necessity of an assistant surgeon (Indicator “0”). 3. Those where an assistant surgeon may not be paid (Indicator “1”) 4. Those where the assistant surgeon concept does not apply (Indicator “9”). In general, EmblemHealth follows the assistant surgeon payment policies established by CMS. Proper documentation to support separate reimbursement of assistant surgeon claims includes the following: 1. For Indicator “1” designated procedures, providers need to document in their operative report why an assistant is required for the surgery. If the chart notes are requested for review, that information must be documented. a. The operative report should document, with specificity, the activities the assistant surgeon performed. A separate operative note by the assistant surgeon or specific documentation of the assistant’s activities within the primary surgeon’s operative note is acceptable. The primary surgeon may elect to have some services performed by an assistant surgeon that are included in the primary surgeon’s reimbursement for the procedure performed. In this case, the assistant surgeon’s services are not eligible for separate reimbursement. Here are examples of these type services: 1. Routine opening and/or closing of the surgical site 2. Performing post-operative monitoring b. The intra-operative record(s) must clearly document the time the assistant surgeon was present in the operative suite (e.g., the assistant surgeon’s “in and out” times should be documented in the anesthesia record, nursing records or other appropriate intra-operative records). 2. For Indicator “0” designated procedures, providers will need to document patient and procedure characteristics which necessitate the services of an assistant surgeon. a. Examples of potentially complicating patient characteristics include extremes of age, obesity, bleeding tendency, immune status, cardiovascular status, metabolic status and concurrent illness. b. Considerations will also be given if the procedure is a component of a complex surgical case as represented by concurrent CPT codes with indicator “2” designation. An assistant surgeon is distinguished from an “assistant-in-surgery.” Generally, assistants-in-surgery are non-MD professionals such as nurses, operating room technicians, or other specially trained professionals, whose services are included in the primary surgeon’s, or the facility’s, reimbursement. These services are not separately reimbursed. Activities performed by assistants-in-surgery include but are not limited to the following: 1. Passing instruments 2. Hands-in-the-wound assistance 3. Other general assistance that does not require the skill of an assistant surgeon There may be times when a physician elects to utilize more than one assistant during the operative session. However, only one assistant per operative session will be reimbursed. Claims for services of an assistant surgeon should be filed with modifier 80, 81, 82 or AS. Use of modifiers is required for proper payment.