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Asst. when resident is in the room???

  1. Default Asst. when resident is in the room???
    Medical Coding Books
    We have some debate as to whether or not we can bill for an Asst. surgeon when a resident is doing a portion of the case... So I could use some help to help clarify this to the docs... In this particular case one doc from our practice preforms the colectomy, the resident cuts through the skin etc... but is not qualified to use the stapler device, therefore another surgeon in our practice is also in the room to asst. with this portion of the surgery. So the resident is listed on the op note as the 1st asst. and they aslo list the surgeon whom helped with the stapling as the 2nd asst... Would it be correct to bill for the 2nd Asst. or not??? We are in a high volume teaching area and this issue comes up often. Thank you for any thoughts and insight on this matter.

  2. #2
    Milwaukee WI
    Default Teaching hospital
    You may bill for an assist ONLY if there is NO QUALIFIED resident available. The primary surgeon MUST specifically document the requirement for an assist, the fact that no qualified resident is available, and a brief description of how other surgeon (or PA or NP) assisted.

    You will use an -82 modifier if the documentation supports billing an assist.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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