Assistants at surgery (non-MD: NP, PA, or CNS)

clark.amy86

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Assistants at surgery (non-MD: NP, PA, or CNS)

Our physicians are lack luster in their documentation of their assistants during surgery, which is causing denials and delays in payment. I am aware of the compliance standards that requires their active role to be documented in the body of the operative report, in addition to their name in the heading and under indications list the need for an assistant.

They are wanting exact verbiage and/or examples of what needs to be there and there isn't much available online in that aspect. I honestly feel like it is up to the physicians to determine this because of the many different surgeries they perform, but HR believes it falls on the coders.

Does anyone have any guidance or an example of proper documentation for this?
 

wynonna

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Does your question apply to co-surgeons, or assistant surgeons as well, or is a summary of the procedure with both MD names on top of Op Note enough?
thank you
 

SharonCollachi

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Per Palmetto GBA:

What type of documentation is needed to support an assistant surgeon's claim?​

Answer
After additional reviews, Palmetto GBA has modified guidance regarding documentation requirements for assistants at surgery or surgical assistants (billed with HCPCS modifier AS and CPT modifiers 80, 81 or 82).

To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant.

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Karen Zupko is a good resource, here: https://www.karenzupko.com/op-note-documentation-tips-every-surgeon-can-use/

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From the AAPC knowledge center: https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/
 

clark.amy86

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Does your question apply to co-surgeons, or assistant surgeons as well, or is a summary of the procedure with both MD names on top of Op Note

Per Palmetto GBA:

What type of documentation is needed to support an assistant surgeon's claim?​

Answer
After additional reviews, Palmetto GBA has modified guidance regarding documentation requirements for assistants at surgery or surgical assistants (billed with HCPCS modifier AS and CPT modifiers 80, 81 or 82).

To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant.

************************************

Karen Zupko is a good resource, here: https://www.karenzupko.com/op-note-documentation-tips-every-surgeon-can-use/

************************************
From the AAPC knowledge center: https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/
Thank you for your comment!

I have shared that and then some with upper management and they stated that is just too much for the physicians to have to document; they want specific dictation examples (in the body of the operative report) and I lost days searching for them. There is just nothing out there on the billing and coding side that is readily accessible for me to find as far as that goes. Like I said before, I believe it is up to the physicians to document this. All I can do is hold their hands, not do their jobs for them.

I have just reached my wits end with this, lol. Thank you again for responding!
 

clark.amy86

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Good lord. They can't even dictate what their assistant did and why they were necessary?? :rolleyes:
Yes:(

Some are only listing the assistant's name in the heading, others are listing the name+detail of what they did after the name (sometimes it's only ancillary, which isn't covered), but none of them are specifically stating what the role of their assistant was in the body of the note. It's all in the heading.

I can't tell them what their assistant did to help them during the surgery because I wasn't there and have zero clinical training. I will tell them the elements that need to be in the operative note, but I can't do it for them. They get paid the big money for a reason!

P.S. I had another meeting with management and they may have taken me seriously, so hopefully we are going to get it fixed soon!
 
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