Wiki Primary surgeon cpt code vs assistant surgeon cpt code

[alcalcthmpsn]

Hello,

We have a coding sheet with the primary surgeons CPT code selection. We also have the Assisting Surgeon CPT code sheet. Each coding sheet have different CPT code choices. After reviewing the Op note, the assisting surgeon CPT code selection is correct. Is there a way to submit the claim with the assisting surgeon choice or should we contact the primary surgeon to correct the cpt code(s)?

What if the assisting surgeon is not an employee of the hospital but the Primary Surgeon is, does that matter?


Thanks!

 

[FTessaBartels]

Hospital or Professional billing?

I am going to assume you are coding the physicians's services.

You code from the documentation, not from any sort of billing sheet the physician may have completed (although I'll admit these sometimes give us a good hint as to what they were doing - or at least think they were doing).

For an assistant surgeon scenario, only the primary surgeon need document the service, clearing noting the assistant surgeon and his/her role in the surgery as part of that documentation. The same code(s) are used for both surgeons with the appropriate modifier appended for the assistant.

Additionally ... if you are in a teaching hospital, there are very speciofic rules of documentation and coding you must follow. Among them, the primary surgeon's documentation MUST include a statement attesting to the fact that there was no qualified resident available for assist.

Hope that helps.

F Tessa Bartels, CPC, CEMC