Assistant Surgeon Billing

rebeccadb

New
Messages
2
Location
San Diego
Best answers
0
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

New
Messages
2
Location
San Diego
Best answers
0
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

Networker
Messages
84
Location
Anchorage , AK
Best answers
0
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.
 
Messages
5
Location
Tuscaloosa, AL
Best answers
0
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.
 
Top