Wiki Billing for Asst. Surgeon

[simplytam]

We are having an ongoing discussion in the office regarding what documentation is needed to bill for an assistant surgeon. We have one physician who is just adding the following paragraph to the body of his op note:

At this teaching institution without a surgical residency, the assistant was present out of medical necessity. There was no qualified resident available. Based on the complexity of the case, a dedicated specialized assistant with advanced training, "Sam Smith", PA-C, was medically necessary and equally participated in the entire surgical case and all procedures in that case.

In your opinion, is this enough to justify billing for the assistant?
Thank you

 

[amyjph]

Does the operative report detail what the assistant did during the case to show they weren't just, "an extra pair of hands". What, specifically, did the assistant do?

Here is a link to a discussion with other info about it.

https://www.aapc.com/discuss/threads/assistant-at-surgery.196416/?view=date#post-538352

 

[simplytam]

Nothing else in the body - just the above note that they were "medically necessary and equally participated in the entire surgical case" etc. I'll look at the other discussion. Thank you for your help.

 

[amyjph]

If it went to an audit situation, even in a case where no resident was available and the CPT is an "always allowed" assistant, if there's no detail it will probably be denied.