43775 Assistant Surgeon Facts
We have been fighting all year appealing adverse determinations for an assist on 43775. After being told by United Healthcare that they follow CMS guidelines and in 2011 CMS changed the fee schedule status code to a 9 (concept does not apply) instead of a 2 (assistant at surgery can be paid) as it was in 2010.
United Healthcare thinks the status indicator "9" means "not allowed" because the status code for the CPT is "N" which means it is not a covered code by Medicare for any provider.
We contacted NCCI and requested clarification of this and the response from NCCI is that United Healthcare has misinterpreted the information. If there are other payers out there denying the assistant surgeon, it is probably the same issue.
We have also written a letter to ASMBS and the response is: an assistant surgeon would be necessary on a Gastric Sleeve due to the complexity.
Yesterday, we met with the Regional United Healthcare Medical Director about this issue and gave him all of our documentation. He made the statement that "this is the first time anyone has said anything about this to us."
He said sometimes they do misinterpret information but could not guarnatee that all of the denials for the assistant surgeon's be reconsidered retroactively. To change corporate policy at the National level is difficult.
I know this is not true because we had a similar meeting in 2005 with the UHC Medical Director regarding the Lap Band. All of our claims were retroactively reconsidered and paid.
The surgeons are deflated and feel defeated since we find out NO ONE has complained about this.
This is my plea to all Bariatric coders: We need to stand together on this and fight for what is correct coding! You all know the Sleeve would require an assistant, just look at the RVU's. Ask your surgeon.
If carriers are going to approve the Sleeve, they need to make sure they have covered the essentials for the safety of the patient, in their coverage policies NATIONALLY!
If your office has a vested interest in the assistant surgeon or is concerned about their patients paying out of pocket for the assistant surgeon, then everyone needs to send complaints to the ASMBS, AMA, ACS and carriers that are denying the assistant surgeon.
We can not fight this alone and really need support from coders, surgeons, and specialty organizations to make a difference.
If anyone is willing to help us, please e-mail me at dwppm@at tx.rr.com
We can make a difference if we all come together Nationwide.