Over my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra set of hands to execute the surgery. That used to be enough for payers, but not anymore.
Payers Want More Info:
Payers no longer consider the assistant surgeon’s name in the header only as sufficient documentation. They want the body of the operative note to indicate what the assistant surgeon contributed to the surgery. They also want documentation in the operative report to explain why an assistant surgeon was used at a teaching institution rather than a qualified resident.
Support Modifier 82:
An “assistant at surgery” is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The “assistant at surgery” provides more than just ancillary services.
The fact sheet states, “Documentation must include information relating to the unavailability of a qualified resident in this situation.”
This means you cannot assume there wasn’t a qualified resident available. To support modifier 82, the operative note should state,
- why there was no qualified resident available; and
- why a non-resident assistant had to assist with the surgery.
When coding or auditing surgeries performed at a teaching facility, make sure this information is included in the body of the operative note.
“The operative note should clearly document the assistant surgeon’s role during the operative session.”
This means that the mention of an assistant surgeon only in the operative note header is not enough to support coding for and billing for an assistant surgeon’s services.
The operative not needs to include what the assistant surgeon contributed to the surgery in the body of the operative note.
Assistant at Surgery indicators:
- 0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity
- 1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at Surgery may not be paid
- 2 = Payment restrictions for assistants at surgery does not apply to this procedure. Assistant at Surgery may be paid