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Thread: surgical assistant

  1. #1
    Join Date
    Apr 2007

    Post surgical assistant

    AAPC: Back to School
    If you are billing a surgical assistant is it sufficient to just have the surgical assistants name dictated on the operative note or do you have to have it dictated in detail in the body of the op note. If it needs to be dictated in the body of the op note where can I find this in writing to be provided for a physician.

    Thanks for your help.

  2. #2
    Join Date
    Apr 2007
    Lewiston, Maine


    The physicians I have worked with have only listed the assistant surgeon's names (PA or NP) on the operative note. I don't believe that there is any documentation anywhere that states that their involvement in detail needs to be dictated within the body of the report.
    Catherine Nolin, CPC

  3. #3

    Default Dalyce Myers, CPC

    Look in the January 2008 CODING EDGE, pg 38-39. There is a very good article about this very subject. I know that the office I used to do surgical coding for would only put the assistant's name at the top of the op note, but I gave them a copy of this article, and they are now making some changes.

  4. #4
    Join Date
    Apr 2007


    January coding edge is what brought up this discussion. The surgeons I work for want to see something in writing from medicare to support this article. After calling medicare they do not have anything that they could provide. There statement was that they follow the guidlines set by the AMA. I emailed them and have not been able to get answers there either.

  5. #5
    Join Date
    Apr 2007
    Louisville, KY


    If I'm not mistaken, there's a CPT Asst. article on this. Search the Forum here and see what you come up with, because I'm almost certain I put it on here for someone else's question.

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

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