Practices lose insurance reimbursement by incorrectly billing surgical assistants. In such cases, the major reason for claim denials is to use the wrong modifier/ not use the modifier. In this article, we tried to cover every aspect of billing for surgical assistants including defining surgical assistants, billing guidelines, reimbursement policies, and accurate use of modifiers. Surgical assistance services can be provided by a Health Care Professional other than a Physician (i.e., Physician Assistants (PA), Nurse Practitioners (NP), or Clinical Nurse Specialists (CNS) in accordance with the requirements outlined in Medicare Claims Processing Manual Chapter 12. Surgical assistants include co-surgeons, assistant-at-surgery, and team surgeons.
- Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative session.
- An assistant surgeon is defined as a physician who actively assists the operating surgeon. An assistant may be necessary because of the complex nature of the procedure(s) or the patient’s condition. The assistant surgeon is usually trained in the same specialty.
- An assistant-at-surgery may be a physician assistant, nurse practitioner, or nurse midwife acting under the direct supervision of a physician, where the physician acts as the surgeon and the assistant-at-surgery as an assistant.
- Under some circumstances, highly complex procedures may require the services of a surgical team, consisting of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and complex equipment. A physician operating in this setting is referred to as a team surgeon.
Billing for Surgical Assistants
An assistant surgeon must be appropriately board-certified or otherwise highly qualified as a skilled surgeon, and licensed as a physician in the state where the services are provided. Services by the primary surgeon will be allowed at 100 percent of the maximum allowance for the primary procedure performed. An additional 16 percent will be allowed to the assistant surgeon if criteria for assistant surgeon services are met. An assistant surgeon may be of the same specialty or subspecialty or may be of a different specialty.
Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available) is used by physicians to bill for assistant at surgery services. When billed with modifier AS (PA, NP, or CNS services for assistant at surgery) the modifiers indicate that a non-physician provider served as the assistant at surgery. Modifiers 80, 81, and 82 should be used for a physician to report an assistant for surgery services. These modifiers are not intended to be used for non-physician reporting assistants for surgery services.
Reimbursement for Surgical Assistants
For explaining the reimbursement for Surgical Assistants, we referred CMS and American College of Surgeons guidelines as its primary source. Reimbursement for co-surgeons is 120 percent of the maximum allowance for the primary procedure divided equally between the co-surgeons. Reimbursement for assistant surgeons is 16 percent of the maximum allowance for the procedure. Reimbursement for team surgery will be determined on an individual consideration basis. Reimbursement for Physician Assistant/Nurse Practitioner/Nurse Midwife may be allowed when medical necessity and appropriateness of assistant surgeon services are met, and when the physician assistant/nurse practitioner/nurse midwife is under the direct supervision of a physician. Separate reimbursement will not be allowed for the hospital-employed physician assistant/nurse practitioner/nurse midwife. The physician assistant/nurse practitioner/nurse midwife reimbursement for a covered procedure is 13.6 percent of the maximum allowed for the procedure.
Billing Guidelines for Co-Surgeons
Services by surgeons of different specialties or subspecialties each performing distinct components of a procedure as primary surgeons will be allowed at 120 percent of the maximum allowance for the primary procedure. Multiple procedure guidelines may apply if additional procedures are performed. Each surgeon should document their distinct operative work in a separate operative report. Claims from both co-surgeons should report the same procedure code with modifier 62 appended. The total allowance for the operative session will be divided equally between the co-surgeons. Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty. When a claim for a non-surgical procedure is submitted with modifier 62 for a co-surgeon, the claim will be denied because the co-surgeon concept does not apply.
Physician Assistant/Nurse Practitioner/Nurse Midwife
A physician assistant/nurse practitioner/nurse midwife must be appropriately certified or licensed in the state where the services are provided, and be credentialed in the facility where the procedure is performed. Reimbursement may be allowed when medical necessity and appropriateness of assistant surgeon services are met, and when the physician assistant/nurse practitioner/nurse midwife is under the direct supervision of a physician. Separate reimbursement will not be allowed for the hospital-employed physician assistant/nurse practitioner/nurse midwife. The physician assistant/nurse practitioner/nurse midwife reimbursement for a covered procedure is 13.6 percent of the maximum allowed for the procedure.
Billing Guidelines for Team Surgeons
Highly complex procedures requiring multiple physicians of different specialties, and other highly skilled personnel and equipment may be considered for reimbursement as team surgery. Reimbursement for assistant surgeons is limited to 16 percent of the maximum allowance for the procedure. Services will not be reimbursed if the above criteria are not met. Procedures that are minor, non-surgical, or that are not of sufficient complexity to require multiple physicians of different specialties and other highly skilled personnel and equipment, do not satisfy the definition of team surgery and will be denied if submitted with modifier 66 (Team Surgery).
Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred multiple resources from CMS, Blue Cross Blue Shield of North Carolina, Moda Health, and UnitedHealthcare to discuss billing for surgical assistants in detail. Still, we recommend reviewing payer billing guidelines and reimbursement policies for accurately billing for surgical assistants. For any assistance needed in billing and coding for surgical services, email us at: email@example.com or call us: 888-357-3226.