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Modifier 80 documentation

  1. #1
    Default Modifier 80 documentation
    Exam Training Packages
    I have written documentation from The Coding Edge as well as other sources that state: the Primary surgeon must dictate in the body of his report what the assistant surgeon did during the surgery. It is not suffient to just list the assistant Dr. at the top of the report.

    At the National Conference a speaker mentioned that the assistant could dictate his own operative report stating what he did, then it was ok to bill the assist, regardless of the primary surgeons notation in the surgical record.

    I need to know which is correct. Any comments. I need written support for being able to bill an assistant dictating his own assist record, if its allowed.


  2. Default
    I don't know of any written guideline that states the Assistant can or can not dictate his own OP report.

    For coding, the Assistant is coded the same CPT codes as the Surgeon. The primary can't code a CABG 33533 and the Assist code 33521. The assist is going to get 33533-80 (or AS).

    The Surgeon has control of the surgical episode and it's his responsibility to dictate a complete/accurate OP report. I have actually encouraged the Assist not to dictate a 2nd report. That only opens the door to possible contradictions.

    If the payer requests the OP report before paying the claim, are you going to send the Surgeon's report or the Assist's report or both? And heaven forbid this ends up in court somewhere down the line and the Atty finds a discrepancy between the 2 OP reports.

    Bottom's not the Assist's responsibility to dictate the OP report. If you have an Assist that has a issue with the Surgeon's OP report not accurately reflecting his services, then that's something that needs to be taken up the chain to QA, Peer Review etc

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