AAPC - Back to school
Results 1 to 2 of 2

Thread: Modifier 80 documentation

  1. #1
    Join Date
    Apr 2007

    Default Modifier 80 documentation

    AAPC: Back to School
    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. #2


    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 line.......it'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

Similar Threads

  1. AS Modifier - needed documentation
    By kristamontes in forum OB/GYN
    Replies: 4
    Last Post: 07-05-2015, 08:28 AM
  2. Modifier 80 documentation
    By stephmhut in forum Modifiers
    Replies: 3
    Last Post: 08-11-2011, 07:42 AM
  3. Replies: 2
    Last Post: 03-24-2011, 07:06 AM
  4. modifier -22 and documentation
    By Lisa Bledsoe in forum OB/GYN
    Replies: 9
    Last Post: 08-12-2009, 03:52 PM
  5. Replies: 3
    Last Post: 12-10-2008, 01:10 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.