Wiki Assisting Surgeons

[gvickers94]

Hi,
When a provider assist with a surgery whether it is orthopedics or just regular surgery, the primary doctor should always document what the assisting surgeon is doing in order for this to be billed, correct? If so, is there any documentation to support this that I could use to educate my providers and mid-levels.
Thanks in advance.

 

[Orthocoderpgu]

Hi,
When a provider assist with a surgery whether it is orthopedics or just regular surgery, the primary doctor should always document what the assisting surgeon is doing in order for this to be billed, correct? If so, is there any documentation to support this that I could use to educate my providers and mid-levels.
Thanks in advance.

When is a PA an Assistant Surgeon?

A physician assistant (PA) serves as an assistant surgeon only to suture and close an incision. There is no documentation that the PA performed any other Payers require the work the assistant surgeon provides the surgeon be delineated in the body of the operative note to bill for assistant...

www.aapc.com

 

[amyjph]

There are a # of posts about it in the forums if you search assistant surgeon or assistant at surgery. See here: https://www.aapc.com/discuss/threads/assistant-surgeon-documentation.185236/?view=date#post-506967

It's a struggle unless a payer has a specific guideline or rule you can find. Surgeons will sometimes be resistant to doing this if they don't document this way already. However, showing them denials and dollars lost for the assistant when they do not document specifics is a good way to change behavior. I have found younger providers more acceptable and open to this than the older generation. There is nothing that says you cannot bill an "always allowed" CPT but if you get a medical records request, it may be denied or recouped if it is not documented what the assistant specifically did. If you have a "sometimes allowed with documentation" you shouldn't bill it unless it is very explicit as to why there was a need for a skilled assistant (and not a nurse, CST, CFA, etc.). 29881 is a good example which would always trip up coders. The provider might use a PA assistant and have them listed but this CPT doesn't allow an assistant without a really good and really well documented reason the payer should pay for it.