Orthopedic Coding Alert

Orthopedic surgeons from the same practice often serve as one another's assistant surgeons, but this can be taboo in teaching facilities where only qualified residents can assist during surgery. However, in cases when no qualified resident is available, append modifier -82 (Assistant surgeon [when qualified resident surgeon not available]) to the surgical assistant's claim.

"The rule is that if no qualified resident is available, another physician can assist," says Diane Nirk, CPC, a coding specialist in the department of orthopedic surgery and rehabilitation at the University of Oklahoma Health Sciences Center. She recommends including a "modifier -82 affidavit" letter with the claim, which many carriers require for claims processing.

The "Assistant at Surgery" local medical review policy (LMRP) for Group Health Inc. (GHI Medicare), the Medicare carrier in Queens County, N.Y., states that the letter must include the following certification:

"I understand that Section 1842(b)(6)(D) of the Social Security Act generally prohibits Medicare Part B reasonable charge payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such service. I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the service. I further understand that these services are subject to post-payment review by the Medicare carrier."

"The letter has to be signed by the attending physician, and there must be a copy in the patient's records and with the billing sheets," Nirk says.

Modifier -82 is most often used during periods when residents are scarce, such as in July when one group of residents is rotating out of the hospital and another has yet to begin. However, Nirk says that modifier -82 also applies when the hospital's residents do not have the appropriate experience to assist at particularly complex surgeries.

According to HGSAdminstrators' LMRP (Pennsylvania's Part B carrier), several factors can warrant the unavailability of qualified residents, such as "involvement in other activities, complexity of the surgery, number of residents in the program, or other valid reasons." The policy also recommends appending modifier -82 "when the services are performed in a teaching hospital that does not have an approved training program related to the medical specialty required for the surgical procedure."

Because your practice might have privileges at several hospitals, you should know which facilities have residency programs. Modifier -82 is not required for assistant surgeons at hospitals without residents, so use discretion when applying it.

Orthopedic coders are familiar with modifier -80 (Assistant surgeon) because it can be used in non-teaching facilities when one surgeon assists another. The operating surgeon reports the normal CPT code (no modifiers are required to indicate that he or she is the primary surgeon), while the assisting physician reports the same procedure code with modifier -80 appended. But modifier -80 is also useful in teaching facilities for other reasons.

Suppose a patient presents to a teaching hospital's emergency room with multiple spinal injuries. The orthopedic surgeon acts quickly to perform spinal reconstructive surgery but chooses a nonresident as her assistant because she doesn't feel that the resident is experienced enough to treat the patient's traumatic injuries. Although the assistant surgeon is not a qualified resident, he can still bill for his services by appending modifier -80 to the surgical code.

This is because most carriers' LMRPs include a caveat for modifier -80's use in teaching facilities, allowing it in emergencies when immediate treatment is required and the surgeon opts not to use the resident.

GHI Medicare's LMRP states that surgical assistants in teaching hospitals may be reimbursed "despite the availability of a qualified resident to furnish the services in the following circumstances":