Assistant Surgeon or a Co-Surgeon

dkaz1

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Hi there:

I have a trauma case where an exploratory laporotomy was performed with liver packing. Dr. B. is the surgeon and Dr. M is the assistant surgeon. In the Op note the dictation states that Dr. M. placed a cutdown venous catheter in the lower tibial area.

How do I code for the cutdown cath placement? Is Dr. M. now a co-surgeon and I should seek a dictated report from Dr. M. for doing the cutdown cath placement? Or, should I just code a cut down cath placement and list the 80 modifier for Dr. M.

Please advise and thank you.

Debbie K
 

mitchellde

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Dr M will need to dictate his own report for this surgery, he was not a co surgeon for this procedure since it is it's own procedure that he did not do just part of, and he did not assist while the other surgeon performed the cutdown. If there is no operative note from the physician that performed the procedure then it cannot be charged.
 
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