Wiki Assistant Surgeon Status Indicator 2


West Point, CA
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Hernia repair done with an assistant surgeon. Assistant surgeons' name is indicated at the top of the report but nowhere else in the document is indicated the work done by the assistant and nowhere in the document is demonstrated the need for the assistant surgeon. What are the documentation requirements for an assistant surgeon for procedure with status indicator 2? Is it enough to just document the assistants name at the top?
Hello baroquecoder,

If the assistant surgeons name and credentials are documented on the operative report I believe that is enough to warrant billing for the assistant. You might want to check with your MAC because some require that the role of the assistant also be documented. Also since Assistant at Surgery Indicator is "2" per CMS the assistant may be paid.

"CMS Definition of Assistant at Surgery Indicator "2"
2 = Payment restriction for Assistants-at-Surgery does not apply to this procedure. Assistant-at-Surgery may be paid."

Hope this helps~

M.Hannus, CPC, CPMA, CRC