Wiki Assistant surgeon billing

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bkhattak

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Hello, I would really appreciate if someone can help me out with billing for an assistant surgeon. I have just started working for a plastic surgeon and he has decided to use an assistant surgeon in one of his surgeries for breast reduction. I would like to know if we have to use different codes or use the same codes with modifiers.
 
bkhattak said:
Hello, I would really appreciate if someone can help me out with billing for an assistant surgeon. I have just started working for a plastic surgeon and he has decided to use an assistant surgeon in one of his surgeries for breast reduction. I would like to know if we have to use different codes or use the same codes with modifiers.
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What kind of plastic surgery is it? Cosmetic, then patient is responsible for provider monies, as well as assistant. If it is insurance, then add the modifier for assistant surgeon.
 
How are we gonna pay for the assistant? Would he just get what we get paid from the insurance and how are we gonna determine his portion of the payment? If we have to do breast reduction with the help of an assistant, do we have to bill the procedure code 19318 twice, one with the modifier 80 and one without the modifier. Or just bill 19318 once with modifier 80?
 
I am bit new to this specialty, that's why I am bombarding you with all these questions. Thanks everybody for your help.
 
bkhattak said:
How are we gonna pay for the assistant? Would he just get what we get paid from the insurance and how are we gonna determine his portion of the payment? If we have to do breast reduction with the help of an assistant, do we have to bill the procedure code 19318 twice, one with the modifier 80 and one without the modifier. Or just bill 19318 once with modifier 80?
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CPT without the modifier for the surgeon and CPT with modifier 80 for the Assistant. Each should receive their own payment.
 
bkhattak said:
-Hello, I would really appreciate if someone can help me out with billing for an assistant surgeon. I have just started working for a plastic surgeon and he has decided to use an assistant surgeon in one of his surgeries for breast reduction. I would like to know if we have to use different codes or use the same codes with modifiers.
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I work for a plastic breast recon surgeon with an assist sx feel free to call me at 727-688-4224. I do very heavy billing out of network and non-par. I also negotiate a lot of their claims.
 
wallacr0 said:
I work for a plastic breast recon surgeon with an assist sx feel free to call me at 727-688-4224. I do very heavy billing out of network and non-par. I also negotiate a lot of their claims.
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Hi! I just left a message for you. I'm looking for someone who bills plastics specifically breast recon. I work for a plastics group and am new to plastics. Love to visit with you about your experience and see if you're available to answer a few questions and/or able to be a mentor.
 
bkhattak said:
Hello, I would really appreciate if someone can help me out with billing for an assistant surgeon. I have just started working for a plastic surgeon and he has decided to use an assistant surgeon in one of his surgeries for breast reduction. I would like to know if we have to use different codes or use the same codes with modifiers.
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You would bill once for the doctor & the same cpt code with the assist modifier. But different insurance companies prefer different mods for assist. Some like the 80 modifier, while others prefer the AS modifier.
 
ashleijackson said:
You would bill once for the doctor & the same cpt code with the assist modifier. But different insurance companies prefer different mods for assist. Some like the 80 modifier, while others prefer the AS modifier.
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The difference between -80 and -AS is not the carrier, but rather who is assisting
-80, -81, -82 is for a physician assisting at surgery
-AS is for qualified NPP assisting at surgery (PA, NP, CNS)
https://www.aapc.com/discuss/threads/surgical-assistant-billing.181838/?view=date#post-497917 is the other post where this and addition info was relayed
 
Seems like you got a lot of answers, which are accurate. You can bill for assist as long as the code allows for an assist. I look up the codes on codify/supercoder to verify that an assist is payable. I'm only a bit confused because you state how do you pay the assist. Is the assist not part of your practice? I would think that they are salaried and not paid per case. As part of your practice their info is loaded into your billing software, and you would bill using their name as provider and add either AS, 80 or 82 mod. on the procedure code. We use AS for our physician assistant, and 82 for the doctor from our practice that assisted. The hospitals they work out of have residents so we use 82 stating that a qualified resident was not available. Basically I enter my primary surgeon charges, and then after verifying if the codes are assistable, I'll enter the assistant physician charges. Good Luck!
 
In terms of how you'll be paid for assistant, it depends on the payer. However, for Medicare or plans that follow Medicare rules, see below.

Per CMS:

For non-physician assistants (-AS modifier): "The A/B MAC (B) shall pay covered PA assistant-at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant-at-surgery services, the actual payment amount that PAs receive for assistant-at-surgery services is 13.6 percent of the amount paid to physicians."

For assistant-at-surgery services performed by physicians (-80, -81, -82 modifier): "The fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment."

Hope this answers your question.
 
Hi, Can someone also please help me related to assisting surgeries. We have PA's assisting Primary Surgeon all the time for surgeries . I bill modifier AS for PA and 80 if any DO, however the confusion is I just started working for this hospital as a coder and I am finding that they are billing for PA with AS modifier but PA is not credentialed to be billed on his own they add Supervising as a DO and now claims are being denied as Multiple surgeons non covered. As per the billing they billed for PA with DO as Supervising (who is not listed on the Op report or any documentation ) and with a Primary Surgeon for different procedures.

We cannot bill Supervising DO when he is not on the Op report but billed him coz PA is not credentialed fully yet to be billed fir himself. Is this correct? I will truly appreciate any help to confirm this. Thank you.
 
Let's take surgery assist out of the equation for a moment.
You should never bill under a different provider for the sole reason that the provider actually performing the service is not credentialed.
There are circumstances where billing under another provider (locum tenens, incident-to) is appropriate. But it is not appropriate for the sole reason of non-credentialed provider.

When claims are submitted properly under a PA, the supervising physician can be there, but the individual who rendered the service should be listed. Surgery claims may not be billed incident-to. For surgical assists by PA/NP, the supervising physician would most likely be the primary surgeon.

Regarding claims denied for multiple surgeons not covered, there are many CPT codes that do not permit an assist. You should check whatever reference you use (online encoder, CPT book, Medicare cumbersome listing) to ensure the procedure allows an assist.

Hope this helps!
 
csperoni said:
Let's take surgery assist out of the equation for a moment.
You should never bill under a different provider for the sole reason that the provider actually performing the service is not credentialed.
There are circumstances where billing under another provider (locum tenens, incident-to) is appropriate. But it is not appropriate for the sole reason of non-credentialed provider.

When claims are submitted properly under a PA, the supervising physician can be there, but the individual who rendered the service should be listed. Surgery claims may not be billed incident-to. For surgical assists by PA/NP, the supervising physician would most likely be the primary surgeon.

Regarding claims denied for multiple surgeons not covered, there are many CPT codes that do not permit an assist. You should check whatever reference you use (online encoder, CPT book, Medicare cumbersome listing) to ensure the procedure allows an assist.

Hope this helps!
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Got it. thank you for your quick response.
So if the PA is not fully credentialed then we cannot bill for him.
If PA is credentialed then we can bill him as rendering with Supervising as Primary Surgeon.
Now we have some Primary Surgeons that are ours and some that come from outside. PA's are all ours. So the our Primary Surgeons can be billed as Supervising as PA would be incident -to but for the outside Primary Surgeons if our PA assisted how do i bill for PA? Who can I put as a Supervising Physician if PA is ours but the Primary Surgeon is not & PA is not fully credentialed or if is credentialed. Coz then i can bill PA as incident to Primary physician. The previous coder before me instructed the staff to bill our PA as rendering and put the Supervising as another of our DO and the referring as Primary Surgeon (ours or outside). Please advise on how can I fix this. Thank you.
 
Surgery may not be billed incident-to which I did put in my original response, which Sharon noticed.
Regardless of participation status, regardless of who the primary surgeon was:
1) Your PA name goes as the rendering provider (box 24J or electronic equivalent)
2) Modifier -AS on CPT that allows an assist.
3) I imagine you bill as a group, and the group name/TID, etc goes on the claim as well (box 25 & 33 or electronic equivalent)
4) The supervising provider is you practice's physician that is supervising the PA. (box 17 with DQ to indicate supervising physician & box 17b)

If there are still some insurances that do not credential PAs, they may have a policy to bill under the supervising physician. In absence of a written policy by a carrier to do so, the claim should be billed with PA name as indicated above.

Intentionally changing the name of the provider for the purpose to get a claim paid that would not otherwise be paid is not something you want to be accused of. Whenever hiring a new clinician, the day the contract is signed (and typically well before start date), I start the insurance credentialing process. If you expect to be paid for a clinician's services, they need to be participating (unless insurance has out of network benefits and pt is informed they are using an out of network provider.)
 
SharonCollachi said:
I think you missed the part where surgery cannot be billed incident-to. Your PA's are out of network until they are not.
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Thank you Sharon. I did miss that the surgery cannot be incident-to. I got it if the PA's are not credentialed they are not to be billed until they are fully credentialed . Thank you.
 
csperoni said:
Surgery may not be billed incident-to which I did put in my original response, which Sharon noticed.
Regardless of participation status, regardless of who the primary surgeon was:
1) Your PA name goes as the rendering provider (box 24J or electronic equivalent)
2) Modifier -AS on CPT that allows an assist.
3) I imagine you bill as a group, and the group name/TID, etc goes on the claim as well (box 25 & 33 or electronic equivalent)
4) The supervising provider is you practice's physician that is supervising the PA. (box 17 with DQ to indicate supervising physician & box 17b)

If there are still some insurances that do not credential PAs, they may have a policy to bill under the supervising physician. In absence of a written policy by a carrier to do so, the claim should be billed with PA name as indicated above.

Intentionally changing the name of the provider for the purpose to get a claim paid that would not otherwise be paid is not something you want to be accused of. Whenever hiring a new clinician, the day the contract is signed (and typically well before start date), I start the insurance credentialing process. If you expect to be paid for a clinician's services, they need to be participating (unless insurance has out of network benefits and pt is informed they are using an out of network provider.)
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Yes, my mistake I missed that surgery cannot be billed incident-to. And thanks for clearing this , if PA's are not credentialed they cannot be billed, If they are then bill as rendering. I am absolutely not going to bill or code incorrectly to get claim paid. I wanted to make it clear that they cannot bill PA under a Supervising Physician just because PA is not credentialed. Thanks a lot for all your help. I truly appreciate it.
 
What happens if my provider is doing a surgery at the hospital and he used a resident what modifier would I use for my primary surgeon?
 
allyson_felice@yahoo said:
What happens if my provider is doing a surgery at the hospital and he used a resident what modifier would I use for my primary surgeon?
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I suggest reviewing modifier -GC Service has been performed in part by a Resident under the direction of a Teaching Physician.
If your situation is not accurately described by -GC and the resident was ONLY an assist, and not under the direction of a teaching physician, then it is possible no modifier is needed for the primary surgeon. No one would be billing for the assist.
 
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