Guidelines for Assistant Surgeon Claims

Blue Cross and Blue Shield of Alabama provides coverage for assistant surgeons for many procedures. An assistant surgeon is considered medically necessary when the complexity of the operation necessitates the primary surgeon have additional skilled operative assistance from another surgeon or a licensed physician assistant.

Payment is made at 25 percent of the allowance for the surgical procedure when a physician or surgeon is the assistant. Reimbursement for physician assistants (PAs) and surgical assistants (SAs) is 70 percent of the 25 percent of the allowed amount for the surgical procedure. For additional procedures performed during the same operative session, major- minor processing guides apply. Add-on procedure codes are not reduced to half guides.

Proper documentation to support separate reimbursement of assistant surgeon claims includes the following:

• The intra-operative record(s) must clearly document the time the assistant surgeon was present in the operative suite. For example, the assistant surgeon’s “in and out” times should be documented in the anesthesia record, nursing records or other appropriate intra-operative records.
  
  
• The operative report should document, with specificity, the activities the assistant surgeon performed. A separate operative note by the assistant surgeon or specific documentation of the assistant’s activities within the primary surgeon’s operative note is acceptable. The primary surgeon may elect to have some services performed by an assistant surgeon and are included in the primary surgeon’s reimbursement. In this case, the assistant surgeon’s services are not eligible for separate reimbursement. Here are examples of these type services:
  
  
• Routine opening and/or closing of the surgical site
  
• Performing post-operative monitoring
  
  
• Other activities performed primarily for the convenience of the primary surgeon. An assistant surgeon is also distinguished from an “assistant-in-surgery.” Activities performed by assistants-in-surgery include but are not limited to the following:
  
  
• Passing instruments
  
• Hands-in-the-wound assistance
  
• Other general assistance that does not require the skill of an assistant surgeon

Generally, assistants-in-surgery are non-MD professionals such as nurses, operating room technicians or other specially trained professionals. Payment for the above activities is included in the primary surgeon or the facility’s reimbursement. Therefore, these services are not reimbursed separately. Also, there may be times when a physician elects to utilize more than one assistant during the operative session. Blue Cross will reimburse only one assistant per operative session. Claims for services of an assistant surgeon should be filed with type service 0 and modifier 80, 81, 82 or AS. Use of modifiers is required for proper payment.

Click here to view the medical policy on the related topic of “Co-Surgeons and Team Surgeons.”

Last Updated March 2010