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Thread: Assistant Surgery Documentation

  1. #1

    Default Assistant Surgery Documentation

    AAPC: Back to School
    How much documentation is required to get the assistant surgeon paid. Can the doctor just put a paragraph in saying that the assistant help in "all parts"?

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    I researched this rather extensively with some outside colleagues recently. Although it is uncommon practice currently (for providers & hospitals), it is a separate record--not done by the physician, but by the asst. surg (whomever that may be). CPT Asst. 1992 (I believe, and thank you, Mr. Bush for helping with that) says something to that effect.

    I say an addendum to the surgeon's record may suffice, as long as it also bears the surgeon's signature as well.

    Good luck.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

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