Billing for 1st Assist-Bariatric sx


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We have a physician who is acting as the "1st assist" physician for cases. It was my understanding for 2 phy's to bill for a sx case there needs to be evidence of "no available resident to assist, complicated case. Does anyone know what is to be considered the required documentation and which part of the chart does it need to be in....(op report, medical chart, HCFA etc). In the event of an audit where would they be looking for this documentation? Thanks for any help!!
Milwaukee WI
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Are you in a teaching hospital?

IF you are in a teaching hospital, then yes, the primary surgeon must indicate in the operative report that there was no qualified resident available in order to be a credentialed provider as assist. In that case you would use the -82 modifier. The required documentation is as simple as: In the absence of a qualified resident, Dr XXX assisted in this procedure by___(whatever s/he did)___.

If you are NOT in a teaching hospital you have no worries (at least with regards to documenting lack of qualified resident).

Hope that helps.

F Tessa Bartels, CPC, CEMC