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Thread: Documentation needed for Assistant Surgeon Billing.

  1. #1

    Default Documentation needed for Assistant Surgeon Billing.

    AAPC: Back to School
    I have a question regarding requirements for billing for Assistant Surgeons. If the primary Surgeon's dictation does not name the Assistant Surgeon, but there is other documentation such as a Labor/Delivery report or Physician's Progress note for the surgery that states the Assistant's name, is this sufficiant to bill for the Assistant Surgeon's services? Or does the Primary Surgeons dictation have to state the Assistant's name?
    Has anyone else had this problem? Thanks for your help.

  2. #2


    The primary surgeon's report should list the secondary surgeon as the assistant. If the second surgeon is doing for example, the approach to the procedure usually our dr's list him as the assist and then say in the OR that Dr. "Smith" performed the approach and will dictate his portion of the procedure under separate report. Then, the second surgeon dictates his portion of the procedure. If the second surgeon is simply acting as an assist for the whole procedure the insurance company usually requires their name to be listed as the assistant and then they primary surgeon dictates something at the end of the OR like "Dr. Smith was present for the entire procedure and helped with suction, irrigation and instrumentation."

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