Assistant Surgeon Billing

rebeccadb

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I work for an orthopedic surgeon who does predominantly worker's compensation billing. Recently, we have gotten denials from some of the insurance carriers denying the assistant surgery due to "the surgeon must specify what specifically the assistant performed." We have never heard of this requirement, and the surgeries are always authorized for an assist. Additionally, these are codes that have the correct Medicare indicator to receive payment for an assist. I found a blog article from 2013 written by Marilyn Holley, CPC, CPC-I, RHIT, CHISP, (https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/) that contained a sentence stating the physician must include these details in their report as well, however, she did not cite the guideline that would require specifics in the documentation of what the assistant did. Due to our recent denials, I was hoping for some help...Is there a requirement for the assistant's actions to be specifically documented in the report? If so, what is the regulation and where is this stated?

Thank you in advance for the input!
 

rebeccadb

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Thank you, Michelle. Unfortunately, the article you attached just provides the same information as the one that I referenced in my first post. The regulation cited does not specify that additional documentation is a requirement for payment. Does anyone know the exact Medicare guideline, CCR, NCCI edit that states that specifically what the assistant did during the surgery must be documented in the op report?
 

michellepilcher

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https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/

Documentation must establish medical necessity for all cases when a surgical assistant is used. Although a payer might not request documentation when a claim is filed, and might choose to pay a claim without review, you shouldn’t file a claim without documentation to support it. An operative note detailing the need for services rendered is not just a coding and reimbursement requirement, but also a compliance and ethical requirement.

The surgeon should specify in the body of the operative report what the assistant actually did. It’s insufficient to simply list the assistant’s name. The surgeon should clearly explain in the “indications” paragraph of the note why an assistant was necessary, and that he or she was involved in the actual performance of the covered surgical procedure, and not simply there to perform other ancillary services.

This is the only information given by CMS.
 
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we are having same issue at my office and I am getting same denials. The Medicare article and AAPC article were all that I could find about the subject. I have even appealed worker's compensation claims where the surgeon documented what was done and they still denied. If the surgeon's assistant only provides what companies consider "ancillary services" or services that say a surgical tech/nurse could provide then the services are not payable.
 
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I work for an orthopedic surgeon who does predominantly worker's compensation billing. Recently, we have gotten denials from some of the insurance carriers denying the assistant surgery due to "the surgeon must specify what specifically the assistant performed." We have never heard of this requirement, and the surgeries are always authorized for an assist. Additionally, these are codes that have the correct Medicare indicator to receive payment for an assist. I found a blog article from 2013 written by Marilyn Holley, CPC, CPC-I, RHIT, CHISP, (https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/) that contained a sentence stating the physician must include these details in their report as well, however, she did not cite the guideline that would require specifics in the documentation of what the assistant did. Due to our recent denials, I was hoping for some help...Is there a requirement for the assistant's actions to be specifically documented in the report? If so, what is the regulation and where is this stated?

Thank you in advance for the input!
What Modifier(s) are you using. When I code for ASST for W/C, I code the CPT code with -AS-80-RT or LT
 

rebeccadb

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Those are the modifiers we use as well. Does anyone have the specific regulation that states a provider is required to document exactly what the assistant performed?
 

katemae84

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The closest document to a regulation that I've been able find so far is in CMS' State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Page 471 in the Hospital Condition of Participation for Surgical Services that says the following (among other things) must be included in the Operative Report:
"Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues)"
I interpret that to mean they want the Surgical Assist's activities documented, and by saying "significant surgical tasks", I think CMS is laying the groundwork for denying claims for Surgical Assists for tasks that can be performed by Surgical Techs. But maybe that's just me!
Here is the link to the PDF:
CMS State Operations Manual, Appendix A
 

Pam Brooks

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New England's MAC, National Government Services has further clarified documentation guidelines for Assistants at Surgery. They indicate, 'Claims for assistant at surgery with a zero (0) indicator in the MPFSDB must have information to support and identify the assistant and support the medical necessity of his/her assistance with the procedure. Listing an assistant on the operative report and making references to "we" and "us" are not sufficient evidence to support medical necessity. There must be a medically valid reason in the operative report for he assistant at surgery for the claim to be paid. If the claim is denied for medical necessity, the appeals process must be followed to submit additional supporting documentation. Claims billed for an assistant at surgery that do not have the assistant listed in the operative report will be denied.'
 

katemae84

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Yes, I've seen that info from NGS as well. The problem is that the quote is specifically referring to surgeries where additional documentation is required to prove that an assist was medically necessary (zero indicator in the MPFSDB), and not ALL assist at surgeries. Of course it's best practice to always include that information, but it's hard to convince the surgeons to do it when there's nothing that says they have to document that information all the time! :)
 
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does anyone know where I can find information that explains operating room ancillary services and what they consist of? Surgeon's assistant claims are being denied stating that if surgeon's assistant only provided "ancillary services" the claim is not payable. I have tried to locate a description of what is considered ancillary services in the OR and have not been successful.
 
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