Wiki Surgical assists

[tiffer1970@gmail.com]

I code for General Surgery and quite often they have PAs assist in surgeries. My practice has me coding the assist at 15% of the actual fee for the surgery. Is this correct? Or should I be billing the full amount for both the surgeon and the assist? Supercoder says to bill full amount for the assist and let the insurance make the adjustment of payment.

Ex: Lap Chole 47562 $1824 for Dr.
Lap Chole 47562 mod AS $273.60 for PA assisting in surgery

Thanks,

 

[thomas7331]

Providers can charge whatever they want for a service, so there is no right or wrong answer to this. But if your practice bases its charge on an amount above the expected payment or the Medicare fee schedule, then it would make sense to reduce the assistant fee accordingly. I'm not sure why Supercoder would tell you what to charge for anything, or why it would not make this adjustment if it is programmed to price your codes for you, but perhaps the programming is only able to price the CPT code and does not take the modifier into consideration.

I would recommend adjusting the assistant fee, otherwise your fees are out of line with your payments and you'll be inflating your accounts receivable. Also, you are likely to get complaints from patients who are out-of-network because you'll be billing them unreasonable charges for the services.

 

[tiffer1970@gmail.com]

Well the $1824 is based on the Medicare fee schedule, but they've been telling me to adjust the price of the assist to 15% of the surgeons' fee, which would be the $273.60. What Supercoder is trying to say (I think) is why make the adjustment on my end, and just let the insurances make the adjustment instead. What I've heard is that every insurance pays for assists at a different rate, some as low as 15% and some as much as 20%. Even my compliance person asked me why I was doing Medicare's job, let them make the adjustment. I'm just wondering if I should be billing the full $1824 for the assist and then letting the insurances make their adjustments. My only worry is that the insurances are looking at my assist fee and only paying 15% of the 273.60 not the 1824. If that makes sense. Are they only paying 15% of 15% or 20% of 15%.

 

[michellepilcher]

I bill the full amount for both providers. Some providers take the allowed, some expect a certain percentage. The only modification I make is a slight change in price because some insurance companies will pay the assist and then deny the surgeon charge. We have policies in place for adjustments per provider direction.

 

[thomas7331]

You should do what your organization instructs you to do on this. Setting fees is the prerogative of the owners and managers - it is a business decision and not a coding decision, unless they have delegated it to you. I recommend to providers that they set the fees based on a percentage above the average expected payment for the service, for the reasons I described above, but ultimately it is up to them to decide what the want to do. There is no compliance issue with regard to charging one fee or another, as long as the practice charges consistently for that same service and does not discriminate with regard to different patients or payers.