what documentation is sufficient for billing a CRNFA for surgery. I tell my Dr he has to describe what she is assisting with and why the need for the assist. Am I wrong? All he does is put her name in the header as ASSIST
The requirements will depend on the payer - some payers are now requiring documentation of what the assistant has done, and in some cases, of medical necessity for the assistant's services as well. However, most payers do not recognize a CRNFA as a provider at all, so with very few exceptions, you cannot separately bill assistant at surgery services for this provider type.
I agree with what Tomas stated above. Should you have a provider type that is recognized (PA, NP, MD, etc.), Palmetto has great guidance published on this topic:
To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant. https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Browse by Topic~Frequently Asked Questions~Surgery-general~ALJSNW3838
You may want to check with your local MAC to see if they have any guidance.