Wiki C-Section Assist

Create Wiki
L

LeaHarris

Networker
Messages
63
Best answers
0
If a provider assists in a c-section do they need separate documentation from the primary surgeon documenting their roll during the procedure or is the primary surgeon listing them as the assistant enough documentation to bill for a c-section assist?

My assistant surgeon is stating that the following documentation is enough for me to bill for her assist on a c-section:



Cesarean Section Procedure Note

Indications: Arrest of descent in 2nd stage

Pre-operative Diagnosis: G1P0 at 38w4d, medical induction of labor for cholestasis of pregnancy, prolonged rupture of membranes, arrest of descent in 2nd stage

Post-operative Diagnosis: Same, s/p PLTCS, viable female infant

Surgeon: Geoffrey S. Maly, MD

Assistants: Annika Maly, MD

Anesthesia: Epidural anesthesia

ASA Class: 1

Procedure Details
 
Hasan

I work in the gyn practice, to bill for the provider who is assisting in the C sec, either the primary surgeon has to mention the role of the assisting surgeon in his/her medical record or the billing assisting surgeon has to mention in his/her record stating the detailed description of his/her role in the C section.

It depends on to whom you are billing, if you bill for a hospital where these two surgeon practices, then the role of assistant surgeon has to be mentioned in the OP note.

Hope this helps....
 
C-section assist

I do OBGYN hospital coding.
The primary surgeon has to document in their Op report the assist’s name. The Assistant Surgeon does not have to write their own Op report.

When billing for the Assist, add Modifer 80 to the Cpt code. If you are in a teaching hospital, you would use Mod 82. If the primary surgeon uses another doctor instead of a resident they must document that in their OP report. The Op report must state that a resident was not available to assist the primary surgeon, therefore another surgeon (then you note their name) assisted in the procedure. You must also state if they assisted in the whole surgery or only a particular part of the surgery.

I hope this helps
 
Elizabeth.Miller2@samcstl.org

I have always been under the impression that you cannot bill an assistant surgeon for C-Sections. Reading these it sounds as if I am incorrect please advise. Thank you.
 
A C-section assist is definitely billable. You just can't use the global codes. You would use 59514-80.
 
CNM assisting

Can a CNM assist in C-section ? I am under the impression that is a no, but would like to hear from others. Thank you.
 
https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Browse by Topic~Frequently Asked Questions~Surgery-general~ALJSNW3838?open

Palmetto GBA 06/04/2018

After additional review, Palmetto GBA has modified guidance regarding documentation requirements for assistant at surgery or surgical assistant (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.

ahg,
https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~Browse%20by%20Topic~Frequently%20Asked%20Questions~Surgery-general~ALJSNW3838?openCPC, CPMA
 
You must log in or register to reply here.
Top