BS&SC
Networker
I have a provider who has done many, many surgeries with an assistant. The Op note I received last week regarding the use of an assistant said it is “standard procedure on a pelviscopy with bilateral salpingectomy.” In documentation, this same provider uses “we” to describe what the assistant surgeon did. As an ex: “we” ligated the mesosalpinx. “We” did the same on the left side.
From all of my research, the primary surgeon should document the actions the assistant makes, as well as establish the medical necessity for the 80 modifier. I have emphasized this many times in the past with this provider and this latest documentation seems to be the provider’s solution to both. I have had feedback not to question the need for an assistant, but from an auditing perspective, I worry that this documentation is not going to be enough to establish medical necessity, let alone show the assistant's actions autonomous of the primary surgeon’s. Thoughts?
From all of my research, the primary surgeon should document the actions the assistant makes, as well as establish the medical necessity for the 80 modifier. I have emphasized this many times in the past with this provider and this latest documentation seems to be the provider’s solution to both. I have had feedback not to question the need for an assistant, but from an auditing perspective, I worry that this documentation is not going to be enough to establish medical necessity, let alone show the assistant's actions autonomous of the primary surgeon’s. Thoughts?