ED Coding and Reimbursement Alert

Question: A patient presented to the ED with a ruptured appendix and had to be taken to the operating room. Because no one else was available, our ED physician served as the assistant surgeon (his ED shift had ended). The ED visit was billed as a level five (99285). How should I bill for the assistant surgery?

Kentucky Subscriber

Answer: Both the primary and assistant surgeon should report the same procedure code (44950, appendectomy). However, the physician assistant should append modifier -80 (assistant surgeon) to the claim to indicate to the payer that he is eligible for a portion of the payment. The reimbursement is based on what your payer contract allows for an assistant surgeon. For example, the reimbursement could be: surgeon 100 percent of the allowable, assistant 16 percent of the allowable. If the total allowable were $500 for an appendectomy, the surgeon would get $500 (including copay) and the assistant $80 (including copay).

You should submit the usual fee (not a reduced one) when billing for the assistant surgeon, because the carrier will reduce the allowed amount. If you reduce the fee, the carrier will reduce it again, and you will get an even smaller amount.