When is a PA an Assistant Surgeon?
A physician assistant (PA) serves as an assistant surgeon only to suture and close an incision. There is no documentation that the PA performed any other function to assist the primary surgeon during the surgery performed on the Medicare patient, such as providing extra hands needed for tasks which required more than the surgeon’s two hands. Can the PA bill out as an assistant surgeon?
This was a follow-up question posed to me in response to my June 17 blog “Assistant at Surgery Modifiers Require Specific Documentation.”
Researching Medicare and Medicare Administrator Contractor documentation, I found nothing about paying for assistant surgeons for only suturing and closing the incision. It is difficult to find something that does not exist. I did, however, find rules which addressed how and when to bill for a PA serving as an assistant surgeon.
First, Check the Payment Indicator for the Service
The HCPCS Level II modifier AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery is used when the PA (or nurse practitioner or clinical nurse practitioner) provides services as an assistant surgeon. Check the Medicare Physician Fee Schedule Database to see if the CPT® codes performed allow payment for a non-physician provider (NPP) before assuming that the NPP will be paid for assistant surgeon services of any kind — documented or not.
If the assistant surgeon indicator is:
0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.
2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
9 = Concept does not apply.
For example, 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling allows modifier AS. But a similar code, with a different approach, 63650 Percutaneous implantation of neurostimulator electrode array, epidural does not allow modifier AS.
Second, Check Payer Guidance
Payers are requiring that the work the assistant surgeon provides the surgeon be delineated in the body of the operative note to bill for assistant surgeon services. You cannot bill for an assistant surgeon just because the assistant is listed in the header of the operative note. The specifics of what the assistant brings to the surgery, such as “additional hands holding retractors while the surgeon is able to resect …” must be included in the body of the operative note to bill out the assistant surgeon’s role in the surgery.
Novitas’ Assistant at Surgery Modifier Fact Sheet states: “The operative note should clearly document the assistant surgeon’s role during the operative session”
Palmetto GBA states in a FAQ on their website: “To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant.” [emphasis added]
A surgery includes the pre-operative evaluation of the patient the surgery, the closure, and the applicable post-operative care, per the procedure’s global care. If the only contribution the PA made to the surgery, that is documented in the operative note, is that they sutured and closed the incision, and the note did not indicate any specific “need” for the PA to do the closure for the primary surgeon, it would be difficult to support to a payer why the PA should be paid as an assistant surgeon.
Terry Fletcher, CPC, CCC, CEMC, CMSCS, CCS-P, CCS, ASC-CA, SCP-CA, CMC, CMCS, said she sees this sort of thing all the time in her consulting and it’s usually because the doctor wants to leave early or complete more cases in a time period. Fletcher added that, in the case above, there is nothing to bill for the PA since they are only closing, which is an activity integral to the surgery and does not require the additional hands of the assistant surgeon. She also said that she would think that this could be a huge compliance and malpractice risk for the physician and facility.