Incorrect billing of surgical assistants can lead to practices losing insurance reimbursement. The primary reason for claim denials in such cases often revolves around the improper use of modifiers or failure to use them altogether. To address this issue comprehensively, our blog covers various aspects of billing for surgical assistants. We delve into the definition of surgical assistants, billing guidelines, reimbursement policies, and the accurate application of modifiers.
Surgical assistance services can be provided not only by physicians but also by other qualified Health Care Professionals, such as Physician Assistants (PA), Nurse Practitioners (NP), or Clinical Nurse Specialists (CNS). These services must adhere to the requirements outlined in Medicare Claims Processing Manual Chapter 12. The scope of surgical assistants includes co-surgeons, assistant surgeons, and assistant-at-surgery roles.
Co-Surgeons are characterized by two or more surgeons working together, each contributing their skills to perform distinct parts of a specific operative procedure. Co-surgery always takes place during the same operative session.Surgical Assistants, on the other hand, actively aid the operating surgeon during a procedure. They are often necessary due to the complexity of the procedure(s) or the patient's condition. Typically, the assistant surgeon is trained in the same specialty as the primary surgeon.An Assistant-at-Surgery may be a physician assistant, nurse practitioner, or nurse midwife working under the direct supervision of a physician. In such cases, the physician acts as the surgeon, while the assistant-at-surgery functions as an assistant.In certain circumstances, highly intricate procedures might require the collaborative efforts of a surgical team, which includes several physicians from different specialties, along with other highly skilled, specially trained personnel and sophisticated equipment. The physician operating within this context is referred to as the team surgeon.Billing Guidelines For Surgical Assistants
To be eligible for the role of a surgical assistant, the individual must possess appropriate board certification or demonstrate exceptional qualifications as a skilled surgeon. Furthermore, they should hold a valid physician's license in the state where their services will be rendered. For services provided by the primary surgeon, reimbursement is normally at 100 percent of the maximum allowance for the primary procedure performed. If the criteria for assistant surgeon services are satisfied, an additional 16 percent reimbursement will be allowed for the surgical assistant.
A surgical assistant may belong to the same specialty or subspecialty as the primary surgeon, or they may come from a different specialty altogether. Physicians can use Modifier 80 (assistant surgeon), Modifier 81 (minimum assistant surgeon), or Modifier 82 (when a qualified resident surgeon is unavailable) when billing for assistant surgery services.
It's essential to note that Modifier AS (PA, NP, or CNS services for assistance at surgery) is utilized by physicians to indicate that a non-physician provider served as the assistant during surgery. On the other hand, Modifiers 80, 81, and 82 should be exclusively used by physicians when reporting an assistant for surgery services and should not be used for non-physician reporting assistants for surgery services.
Reimbursement For Surgical Assistants
Based on CMS guidelines and the American College of Surgeons, for co-surgeons, the reimbursement is set at 120 percent of the maximum allowable for the primary procedure, which is then evenly divided between the co-surgeons. The surgical assistants are eligible for reimbursement at a rate of additional 16 percent of the maximum allowance for the procedure.
Regarding team surgery, reimbursement will be determined on a case-by-case basis, considering individual circumstances. In the case of Physician Assistant/Nurse Practitioner/Nurse Midwife services, reimbursement may be allowed if medical necessity and appropriateness of their assistance are met under the direct supervision of a physician. However, separate reimbursement will not be provided for hospital-employed Physician Assistants/Nurse Practitioner/Nurse midwives.
For covered procedures, the reimbursement rate for Physician Assistant/Nurse Practitioner/Nurse Midwife is set at 13.6 percent of the maximum allowed for the respective procedure.
Billing Guidelines For Co-Surgeons
In the context of surgical services, it is permissible for surgeons from different specialties or subspecialties to collaborate on a procedure, with each surgeon performing distinct components as the primary surgeon. Under this arrangement, the maximum allowance for the primary procedure is normally set at 120 percent. In cases where additional procedures are conducted, multiple procedure guidelines may be applicable.
To ensure proper documentation, each surgeon involved in the procedure must submit a separate operative report detailing their specific operative work. Claims from both co-surgeons should use the same procedure code, with modifier 62 appended.
Regarding payment, the total allowance for the operative session will be divided equally between the co-surgeons. However, it is important to note that claims for co-surgeon services will be denied when both surgeons have the same specialty or subspecialty, as they are not considered distinct specialties in this scenario.
Additionally, if a claim for a non-surgical procedure is submitted with modifier 62 for a co-surgeon, it will be denied, as the co-surgeon concept is not applicable to non-surgical procedures.
Billing Guidelines For Team Surgeons
Complex procedures that necessitate the involvement of multiple physicians from diverse specialties, as well as other highly skilled personnel and specialized equipment, may qualify for reimbursement under the category of team surgery. However, reimbursement for assistant surgeons in such cases is limited to 16 percent of the maximum allowance for the procedure. It is important to note that services failing to meet the aforementioned criteria will not be eligible for reimbursement. Furthermore, procedures that are minor, non-surgical, or do not require the expertise of multiple physicians and highly skilled personnel, will not be considered team surgery and will be denied if submitted with modifier 66.
Schedule An Appointment With Professionals Now!
TriumpHealth is a leading medical billing company providing end-to-end medical billing and coding services. They offer a wide range of services that can help you increase your revenue and prioritize the health of your patients. To explore more about their surgery billing and coding solutions, connect with TriumpHealth today at (888) 747-3836 x0 or [email protected].
Sign in to leave a comment.