Neurosurgery Coding Alert

An indicator of “1” tells you that an assistant at surgery will never be paid.

When you need to append modifiers to your neurosurgeon’s procedures, your claims could be in jeopardy if you don’t understand the specific rules to follow. For example, if your neurosurgeon acts as an assistant surgeon during a procedure, you should be familiar with the three types of assistant surgeon modifiers.

Read on to learn more.

Why Assistant Surgeon Could Be Needed

A primary surgeon may use an assistant surgeon for several reasons, such as a particularly complex procedure or patient condition. In this case, the assistant surgeon works under the direct supervision of the principal surgeon.

Medicare requires the primary surgeon to list the assistant surgeon in the operative report and to make some notation within the procedure description regarding how the assistant was involved.

Sometimes the surgeon you code for might act as the primary surgeon on the case, and sometimes he might act as the assistant surgeon, which will impact your coding. The primary surgeon should bill the procedure without a modifier, while the assistant surgeon must append the appropriate modifier to the same procedure code.

Definition: According to Medicare guidelines, “an assistant at surgery must actively assist when a physician performs a Medicare-covered surgical procedure. This necessarily entails that the assistant be involved in the actual performance of the procedure, not simply in other, ancillary services.”

Medicare guidelines continue: “Since an assistant would, thus, be occupied during the surgical procedure, the assistant would not be available to perform (and thus, could not bill for) another surgical procedure during the same time period.”

Append Modifiers 80, 81, and 82 for Assistant Surgeon

Medicare will only pay for a surgical assistant when the procedure performed is authorized for an assistant, and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP), or a clinical nurse specialist (CNS).

“It is important to note that CMS uses the terms ‘surgical assistant’ and ‘assistant at surgery’ for both physicians and qualified physician-extenders,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “However, CPT^® uses the term ‘assistant surgeon’ to describe a physician assisting at surgery, while CMS uses the term ‘assistant at surgery’ for a qualified physician-extender.

CPT^® provides the following three assistant-surgeon modifiers, which are applicable to physicians and not physician-extenders, when reported alone:

• 80 (Assistant Surgeon)
• 81 (Minimum Assistant Surgeon)
• 82 (Assistant Surgeon when qualified resident surgeon is not available)

As you can see, the distinction between modifiers 80 and 81 lies in whether the assistant surgeon participates during the entire procedure or just a portion of it.

Modifier 82: You should reserve modifier 82 for cases in a teaching hospital when a qualified resident is not available, so an assistant surgeon participates in the entire procedure. Medicare defines “qualified resident not available” to mean the following circumstances:

• A resident was unavailable because he was working on another activity.
• The surgery was complex, and the resident did not have the necessary skills to assist.
• There were not enough available residents in the residency program.
• The patient’s condition was emergent or life-threatening and required immediate treatment.

Use Modifier AS in Specific Cases

When a PA, NP, or a CNS assists at surgery, you should append modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to the surgical code along with modifier 80.

Without modifier AS, modifiers 80, 81, and 82 indicate that a physician was the surgical assistant. So, claims you submit that include modifier AS without modifier 80, 81, or 82 will be returned to you.

Caution: Many commercial insurers follow Medicare’s rules, but not all do. Be sure to query each of your payers to find out their policies on billing for surgical assistants. They may want only the modifier AS, or they may not recognize it at all.

Double-Check Assistant Surgery Indicators

Before you bill for an assistant at surgery under the Medicare Physician Fee Schedule (MPFS), you should always double-check the ASST SURG column to verify that the procedure(s) allows an assistant.

Payers will not reimburse you for assistants at surgery in all cases, regardless of the modifier(s) you attach to the claim. For Medicare, assistant at surgery services are eligible for reimbursement only when national claims data indicates the procedure would require an assistant in at least 5 percent of the claims based on a national average, according to Medicare guidelines.

Look for these designations in the ASST SURG column:

• “0” indicates that Medicare will allow payment (upon satisfactory review) for an assistant at surgery if you submit supporting documentation to establish medical necessity.
• “1” tells you that an assistant at surgery will never be paid. You should never apply modifiers 80 or AS to these codes.
• “2” means that Medicare will routinely pay for the procedure in conjunction with an assistant surgeon. Append modifier 80 for an assistant surgeon or modifier 80 and AS for an assistant at surgery to these codes to indicate that an assistant surgeon/assistant at surgery was involved with the case respectively.
• “9” indicates that the assistant at surgery concept does not apply. You should never attach modifiers 80 or AS to these codes. Many of the N status or noncovered codes carry a 9 in the assistant at surgery column.

Example: Code 61055 (Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment) has a “1” indicator for modifiers 80, 81, and 82. So, an assistant surgeon will never be paid for this service.