Coding for an assistant in an arthroscopic Bankart repair

codemeister

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I have a question about how to report codes for an assistant (such as a PA) for an arthroscopic shoulder capsulorrhaphy. For example, if the operative session consists of the capsulorrhaphy (29806), extensive debridement (29823) and a subacromial decompression with partial acromioplasty (+29826), billing and bundling situations apply.
The 29823 is bundled into the 29806, so for the primary surgeon the coding would be 29806 followed by 29826.

However, for the assistant, the billing gets complicated, because 29806 is not reportable by the assistant. This is because, according to the MPFS, 29806 is classified as an "Assistant at Surgery Status 1 Indicator" code which to the best of my understanding and those in my professional circle means that it's inappropriate to bill this code for the assistant regardless of the payer. Since the debridement is bundled into the Bankart repair, and 29826, which is not bundled, is just an add-on code, how do we report the assistant's services?

I've gotten suggestions that range from reporting the Bankart (29806) anyway with the SAD (29826) just as with the primary surgeon, to reporting 29823 followed by 29826 since the debridement work was done and the assistant would get credit for it, to reporting nothing at all since you can't report an add-on code alone.

Any thoughts or referrals to documentation on this specific subject welcome!
 

AReilly

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I have a question about how to report codes for an assistant (such as a PA) for an arthroscopic shoulder capsulorrhaphy. For example, if the operative session consists of the capsulorrhaphy (29806), extensive debridement (29823) and a subacromial decompression with partial acromioplasty (+29826), billing and bundling situations apply.
The 29823 is bundled into the 29806, so for the primary surgeon the coding would be 29806 followed by 29826.

However, for the assistant, the billing gets complicated, because 29806 is not reportable by the assistant. This is because, according to the MPFS, 29806 is classified as an "Assistant at Surgery Status 1 Indicator" code which to the best of my understanding and those in my professional circle means that it's inappropriate to bill this code for the assistant regardless of the payer. Since the debridement is bundled into the Bankart repair, and 29826, which is not bundled, is just an add-on code, how do we report the assistant's services?

I've gotten suggestions that range from reporting the Bankart (29806) anyway with the SAD (29826) just as with the primary surgeon, to reporting 29823 followed by 29826 since the debridement work was done and the assistant would get credit for it, to reporting nothing at all since you can't report an add-on code alone.

Any thoughts or referrals to documentation on this specific subject welcome!
Depending on the payer, the assistant can be payable for CPT 29806 which then you could bill CPT 29826 as well. I code for providers in Georgia and a few payers, for example GA Medicaid, Aetna, AmBetter, and BCBSGA Anthem, follow the American College of Surgeons (ACS) recommendations as to which procedure is payable for the assistant vs Medicare's fee schedule. There are a few CPT codes on the ACS list that are payable whereas Medicare says they are not payable. This is the case for CPT 29806.

If the payer follows Medicare's fee schedule as to paying the assistant, then you shouldn't bill anything for the assistant. CPT 29806 is not payable for the assistant and the add-on code is only payable when the parent code is paid. Even if you get paid for the 29826, this doesn't mean its paid correctly. Because in the coding world, you know add-on codes should only be paid if the parent code is paid. Also, you wouldn't bill the 29823 and 29826 for the assistant because the assistant's claim should match the primary surgeon's claim.

I keep an excel sheet to track which payers follow Medicare vs ACS recommendations to when the assistant is payable so that the assistant's reimbursement doesn't fall through the cracks. The payer will list which guideline they follow in their reimbursement policies or in their provider manual.
 

AReilly

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That is not true, the assistants claim does not have to mirror the surgeon's claim.
Does the assistant's claim not have to match the surgeon's claim based on a payer rule? I have read in provider manuals, the assistants claim should exactly match the surgeon's claim. This is the first I'm hearing that the assistant can bill different codes the surgeon didn't bill.
 

Orthocoderpgu

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Does the assistant's claim not have to match the surgeon's claim based on a payer rule? I have read in provider manuals, the assistants claim should exactly match the surgeon's claim. This is the first I'm hearing that the assistant can bill different codes the surgeon didn't bill.
You may find some individual payers that request that the assistants claim mirror the physicians. In those cases you would need to follow payer policy. However, it's not always necessary. Most insurance companies now process the surgeon's and assistants claims separately without comparing the two. One reason for this is that claims are now submitted electronically to insurance. The software then just looks at the codes submitted and makes payment if there are no NCCI conflicts without any human involvement. The software has no idea if an assistant is being billed at the same time or not. We commonly bill 29888 and 29881 together. Code 29888 allows an assist while 29881 does not. Both codes are submitted on the surgeon's claim, but only 29888 is submitted on the assistants claim.
 

Lpackard

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I have often wondered why a comprehensive code like 29806 does not allow for an assistant yet codes that are less comprehensive and have fewer RVU's like the 29823 and 29826 do allow for an assistant! It makes no sense! If 29823 which again does allow for an assist is bundled (a component of) 29806 the more complex procedure... then it stands to reason that the more comprehensive procedure would cover services for an assistant? What authoritative body can actually look at this scenario and consider changing it so 29806 will allow assist billing? I think that is the underlying issue here and needs to be addressed/changed!
If the assist billing does not have to mimic the surgical billing then it makes sense to at least capture in-part what the assist is billing using the 29823 and 29826 at this point in time. However again, seems like the assist is still not getting a fair shake. Billing absolutely nothing for the assist is even more disheartening! Is there anything in writing from CMS or other authority that states the assistant claim MUST mimic the surgeon's claim? If not then perhaps billing the 29823 and 29826 for now until a correction can be made on 29806 may be the more correct way to go!
 

Orthocoderpgu

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I have often wondered why a comprehensive code like 29806 does not allow for an assistant yet codes that are less comprehensive and have fewer RVU's like the 29823 and 29826 do allow for an assistant! It makes no sense! If 29823 which again does allow for an assist is bundled (a component of) 29806 the more complex procedure... then it stands to reason that the more comprehensive procedure would cover services for an assistant? What authoritative body can actually look at this scenario and consider changing it so 29806 will allow assist billing? I think that is the underlying issue here and needs to be addressed/changed!
If the assist billing does not have to mimic the surgical billing then it makes sense to at least capture in-part what the assist is billing using the 29823 and 29826 at this point in time. However again, seems like the assist is still not getting a fair shake. Billing absolutely nothing for the assist is even more disheartening! Is there anything in writing from CMS or other authority that states the assistant claim MUST mimic the surgeon's claim? If not then perhaps billing the 29823 and 29826 for now until a correction can be made on 29806 may be the more correct way to go!
Don't consider 29823 as BUNDLED with 29806. It's not. The President of AAOS met with CMS for several years trying to get CMS to understand "debridement" which they still have not done even though it's been spelled out plain as day multiple times. However, the President of AAOS did get CMS to allow debridement, code 29823 only, to be paid when paired with 29824, 29827 & 29828. It cannot be billed with any other code such as 29806, which is why I say it's not bundled it's just not allowed per CMS. Most restorative procedures also start out with debridement such as 29827, 29828. As such, the debridement that's done in order to perform 29827 & 29828 and other restorative procedures cannot be counted towards 29823. The debridement has to be performed for an unrelated reason and not part of a restorative procedure. I'm with your though, if an assistant is allowed for 29827 why not 29806? They both have employ moving internal tissue and using sutures to hold the tissue in place. I'm not aware of any CMS policy that states that the assistant's codes must mirror the surgeon's codes.
 

codemeister

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Thank you for all your feedback! My long-term understanding regarding the assistant's codes mirroring the primary (or not reporting any code not billed on the primary claim) is that yes, probably about 99.5% of the time that is true. However, there are exceptions. One classic example is when an obstetrician performs a complicated C-section that requires an assistant. The primary will report the global delivery code of 59510. However, obviously the assistant isn't going to bill the global code, because he/she was present only for the delivery and not the antepartum/postpartum care. So the assistant would report 59514-80, not 59510-80.

Here in eastern Massachusetts, I am not aware of any payers that do not follow CMS's regulations with regard to Status 1 codes, and had been advised (more than 10 years ago) that it's inappropriate to report a Status 1 code for an assistant.
 
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