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Thread: Medical Documentation

  1. #1

    Default Medical Documentation

    AAPC: Back to School
    What is the requirements for medical documentation to support the use of a surgical assistant in a procedure and where in writing can I get this information? Thank You

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Teaching hospital?

    You need to document the name/license of the assistant (MD, PA, NP, DO, etc), as well as that person's role as assistant.

    Additionally, if you are in a teaching hospital, you much document the fact that no qualified resident/fellow was available to assist.

    The assistant surgeon does NOT need to dictate a separate operative note. (Co-surgeons, however, must each dictate their own operative notes.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3


    Thank You ,but let me ask another question. Is it appropriate to dictate in the op-report as such; First Assistant--John Doe PA-C Surgical assistant is medically necessary and indicated due to the complexity of this surgery. Minimally invasive surgical technique requires 2 sets of trained hands for retraction, leg positioning and application of jigs. Is this enough documentation?

  4. #4

    Default Surgical assists

    If the payer usually does not pay for an assist for a particular code , but you have a complicated or unusual case, you will have to appeal the denial with documentaion stating why or what made the case complicated. (ie.. patient weigh of 350 lbs , required additional surgical hands to "blah, blah , blah"

    kathy H.

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