If a provider assists in a c-section do they need separate documentation from the primary surgeon documenting their roll during the procedure or is the primary surgeon listing them as the assistant enough documentation to bill for a c-section assist?

My assistant surgeon is stating that the following documentation is enough for me to bill for her assist on a c-section:

Cesarean Section Procedure Note

Indications: Arrest of descent in 2nd stage

Pre-operative Diagnosis: G1P0 at 38w4d, medical induction of labor for cholestasis of pregnancy, prolonged rupture of membranes, arrest of descent in 2nd stage

Post-operative Diagnosis: Same, s/p PLTCS, viable female infant

Surgeon: Geoffrey S. Maly, MD

Assistants: Annika Maly, MD

Anesthesia: Epidural anesthesia

ASA Class: 1

Procedure Details