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Wiki Assistant Surgeon Documentation for Modifier 80

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dballard2004

dballard2004

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I have specific question on what documentation is required to code/bill separately for an assistant surgeon with modifier 80...

My understanding is that the primary surgeon has to document in the op note the reason why an assistant surgeon was needed (medical necessity) and the services provided by the assistant during the procedure. I have a breast surgeon who performed a left axillary dissection with an assistant surgeon. The note just states....

"Dr. XXXX assisted with the case due to prior scarring to decrease the operative time and preserve the nerve function."

Is this sufficient to code/bill for the assistant surgeon? I say no since there is no more detail as to what the assistant actually did, but I have a coder who states this is correct documentation to code the assistant.

Thoughts/Insights please? Thanks.
 
See here: https://www.aapc.com/discuss/threads/use-of-“we”-for-modifier-80.189726/?view=date#post-526500

It's a common debate. If there is a named assistant at surgery and the code is an "always allowed" type, most coders will just bill it. Providers usually expect the same. However, in a audit situation or "technically" you aren't supposed to (my view). The best advice is to clearly document exactly what the assistant did and why it was necessary. Why couldn't a surgery tech assist? etc.
 
I agree with Amy that historically, most surgeons do not "properly" document the assistant surgeon. I don't think I've ever seen an op note that specified in the body of the note exactly what was done by the assistant. At best, it's just a statement like "Dr. B assisted throughout the procedure to provide additional retraction, access and cautery."
A couple of MACs have some advice about it, but it is kind of vague. Really just to document why and what the assist did.

Assistant at Surgery Modifiers Fact Sheet

www.novitas-solutions.com www.novitas-solutions.com
 
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