Wiki Assistant surgeon documentation

vcar

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I work for a large multi-speciality group. Surgeons often use other same specialty surgeons as assistants during surgical procedures. in the past they have been allowed to just list the assistant‘s name in the header of the op note. I am asking them to include the reason the assistant was necessary in the body of the op-note to justify medical necessity for the assistant. To say I am getting major push back is an understatement. Does anyone have guidance from AMA or CMS that I can use? All I can find is from AAPC and also Karen Zupko but the providers want something from a clinical guidance documentation authority. I need to get them something by the end of the week. Any assistance Is greatly appreciated. Thanks.
 
What I have done is show them assistant at surgery denials where all the op note shows is the name but no description of what the assistant actually did. It's usually commercial payers and not MCR where I have seen these denied. The MACs sometimes have guidance on this so you could check there too. This is tough to find, I have had the same struggle as you. Approach it from a reimbursement perspective. Wouldn't we want to do everything possible to make sure the claim is paid quickly and avoid denials if the op report is requested? While it's nice to have an assistant statement in the header, I have also seen what they did indicated in the body of the report. Search in the forums here, I'm sure this is often discussed. Teaching facility rules are different of course.

To me this wording means you have to explain and justify what they did:
Definition:
An "assistant at surgery" is a physician/non-physician practitioner (NPP) who actively assists the physician performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services.

I realize your question is related to surgeon assistants and not PA but here is a PA reference:
110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants (Rev. 2656, Issuance: 02-07-13, Effective: 02-19-13, Implementation: 02-19-13) Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for services that a PA furnishes as an assistant-at-surgery. Specifically, when a PA actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the PA’s services are eligible for payment as assistant-at-surgery services. For additional policy requirements concerning assistant-at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, pub. 100-04. 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. The AS modifier must be reported on the claim form when billing PA assistant-at-surgery services.

Cigna actually states it (this is from 2018 so would need to check for updates):

Assistant Surgeons: An assistant surgeon must be a licensed physician who has knowledge, training, and experience in the type of surgical procedure being performed and who actively assists the primary surgeon through the entire procedure. Generally, the assistant surgeon: • assists with less difficult aspects of the primary procedures; • does not conduct a preoperative work-up on the patient; • does not admit the patient for surgery; and • is not responsible for postoperative care. The medical necessity for use of the services of an assistant surgeon must be well documented in the operative report. Note: If a co-surgeon (second primary surgeon) acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or 82 added, as appropriate. One assistant surgeon will be reimbursed per procedure

From an auditing/data analytics perspective if we saw a surgeon routinely using another surgeon to assist (rather than a tech, PA, etc.) medical records may be requested. If all of those reports only stated a name but did not justify medical necessity or indicate what the assistant did we might want to dig further and I could see recoups possibly happening. This is probably less likely to be seen on more complex cases (spine vs. TKA for example) even though both are "always allowed" for assistants.
 
Thank you so much for your response, I greatly appreciate it.
 
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