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Thread: Assistant Surgeon

  1. #1

    Default Assistant Surgeon

    Does anyone have anything in writing that states an assistant surgeon needs to do their own documentation of the surgery? Or is it enough that the surgeon states that he was assisted by....

    Any help would be greatly appreciated!

  2. #2

    Default

    Sorry, I wish that I had something written. I work in a teaching facility so ours may be a little different. When I bill for an assistant, the primary dicates the op-report with the statement that he was assisted by ____. Since we are teaching we have to have a separate statement that no qualified resident was available and we use a mod 82. For non-teaching you would probably use an 80. I have not asked my assists to provide any additional documentation the primary op-report should suffice.
    Rachel C. Ashley, CPC-E/M
    Houston, TX

  3. #3
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    Default Co Surg vs Assist Surg

    If the "second" surgeon is truly an assistant - then no separate dictation is required. The primary surgeon merely needs to state "assisted by ____." (and the no qualified resident statemetn if in a teaching hospital). Use -80 or -82 depending on if you're in a teaching hospital setting.

    If the "second" surgeon is actually a co-surgeon - then each surgeon must dictate an operative report and you bill the same CPT to both with -62 modifier on both claims.

    F Tessa Bartels CPC

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    Default

    I read in a previous issue of General Surgery Coder's Pink Sheet that when using the assistant surgeon modifier, you do not need to dictate your own operative report. You just need to be listed as the assistant surgeon on the primary surgeon's operative report. I don't have access to the issue right now. When I get back to the office, I will let you know which issue it was in.

    Melissa Blow, CPC

  5. #5
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    Default

    I found the information in the General Surgery Coder's Pink Sheet July 2007, Vol. 6, No. 7 pages 4 - 5. I hope this helps.

    Melissa Blow, CPC

  6. #6
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    Default

    In addition to listing the assistant surgeons name, our payors require documentation for the need and role of an assistant surgeon. There is an excellent article about this in the January 2008 Coding Edge, page 38. I made a copy of this article for my surgeons and have had excellent results.

  7. #7
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    Default

    Quote Originally Posted by FTessaBartels View Post
    If the "second" surgeon is actually a co-surgeon - then each surgeon must dictate an operative report and you bill the same CPT to both with -62 modifier on both claims.

    F Tessa Bartels CPC
    Is there a place I can find documentation supporting this statement? It only makes sense, really. But I am having trouble documenting this to our surgeons & I'm probably going to be opening a big can of worms with this. If there is written documentation somewhere, it would definitely help me along. I'm not finding anything on the CMS or OIG website. Thanks!

  8. #8
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    Default

    You're right...I had some difficulty finding this on CMS. I was, however, able to locate something on my local website. Maybe this will be helpful.

    Appropriate Use of Modifier -62 for Co-Surgery
    Recently, CIGNA Government Services Medical Review found that several providers were incorrectly appending the modifier -62 to every surgical procedure code billed during the same surgical session. The AMA CPT 2001 descriptor for modifier -62 says that "When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single definitive procedure code. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add on procedure(s)) are performed during the same surgical session, separate code(s) may be reported without the modifier -62 added."

    There are four guidelines that should be used when billing for co-surgery.

    Modifier -62 is for use by two surgeons who work together as primary surgeons.
    Modifier -62 should be added to the primary procedure. Each co-surgeon should use modifier -62 only once. It should not be linked to additional codes, including add-on codes.
    Each of the co-surgeons may act as an assistant surgeon for additional procedures.
    Surgeons of the same or different specialty can use modifier -62, but unlike assistant surgeons, each co-surgeon must dictate a separate operative report documenting his/her distinct operative work. The operative report should indicate the medical necessity for having two surgeons act as co-surgeons.

    Look on page 37 on the below link.

    http://www.cignagovernmentservices.c...1/101_mod3.pdf

  9. #9
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    Default More questions on assistant documentation

    I have a question on this. We were recently told by our State Medical Society that our surgeons should be documenting why they needed an assistant surgeon and what the assistant did. Our surgeons have come back asking exactly what they should be saying. They feel it's obvious why they needed an assistant on a major surgery that allows one and they are wondering exactly what and how much they need to document on what the assistant did. Could someone give us an example of some of the wording they use?

  10. #10
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    Default

    2017 ICD-10-CM Coding Book
    What we are having our surgeons do is at the beginning of the op report they make a statement like "Due to the complex nature of this procedure, PA John Smith was present and assisted me through out" or whatever the reason is that they have an assistant.

    Then in the op report itself we have them identify who did what by using terms like I, we, or the assistants name, such as "I opened...." "We then..." "PA Smith harvested the....".

    These are just brief examples but hopefully they will help you.

    Laura, CPC

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