General Surgery Coding Alert

Question: We just received a rejection for an assistant surgeon fee for an epigastric hernia repair (49572-80), although we’ve been paid in the past. How can I find out if modifier 80 is allowed with this procedure?

Codify Subscriber

Answer: Code 49572 (Repair epigastric hernia [e.g., preperitoneal fat]; incarcerated or strangulated) is billable with modifier 80 (Assistant surgeon). You can look at the Medicare physician fee schedule data base column for “Asst Surg” or use a look-up tool such as Codify to see what modifiers are allowed with a specific code. 

However, even if the modifier is allowed, lack of documentation or other circumstances may result in a denial. 

For instance: If your physicians perform the epigastric hernia repair in a teaching hospital, Medicare won’t pay for an assistant surgery claim with modifier 80, but may cover the assistant claim if you use modifier 82 (Assistant surgeon [when qualified resident surgeon not available]).

That’s just one example of what could cause the denial, so you’ll need to review your documentation and perhaps contact your payer to understand the problem for sure.