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What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Click here for more sample CPC practice exam questions and answers with full rationale

Access CPT® Assistant Articles on Codify

Research codes without slowing your workflow. The authoritative guidance in the American Medical Association’s CPT® Assistant can help you code procedures more accurately and is a trusted go-to resource for when providers and payers have procedural coding questions. If your Codify package includes Code Connect, the CPT® Assistant search add-on, one of the many ways […]

The post Access CPT® Assistant Articles on Codify appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

2 Tips for Billing a Physician Assistant as Assistant Surgeon

A physician assistant (PA) serves as an assistant surgeon only to suture and close an incision. There is no documentation that the PA performed any other function to assist the primary surgeon during the surgery performed on the Medicare patient, such as providing extra hands needed for tasks which required more than the surgeon’s two […]

The post 2 Tips for Billing a Physician Assistant as Assistant Surgeon appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Assistant at Surgery Modifiers Require Specific Documentation


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


Coding Ahead

Assistant at Surgery Modifiers Require Specific Documentation

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 […]

The post Assistant at Surgery Modifiers Require Specific Documentation appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Assistant Surgeons and Co-surgeons together

I code for urology, and have a radical nephrectomy surgery case where two of our MD’s performed the nephrectomy together, one was primary, and the other the assistant surgeon. This is what we often see, and will add modifier 80 to the assistant surgeon, however, the patient had some aortic bleeding and a vascular surgeon was also involved in the case, so from a different specialty. I do not know the rules or guidelines on coding for co-surgeons, when there was also an assistant surgeon from our specialty involved in the case.

Normally we would code the CPT code for the primary surgeon, and then code the CPT again for the assistant surgeon with modifier 80.
since there was also a co-surgeon involved from a different specialty, would we add modifier 62 to the primary surgeon’s CPT to support the co-surgeon or is this not allowable when an assistant is also involved; does that "overrule" the assistant surgeon in this case?

Medical Billing and Coding Forum

Assistant Surgeon Status Indicator 2

Hernia repair done with an assistant surgeon. Assistant surgeons’ name is indicated at the top of the report but nowhere else in the document is indicated the work done by the assistant and nowhere in the document is demonstrated the need for the assistant surgeon. What are the documentation requirements for an assistant surgeon for procedure with status indicator 2? Is it enough to just document the assistants name at the top?
Thanks!

Medical Billing and Coding Forum

Assistant Surgeon Billing

I work for an orthopedic surgeon who does predominantly worker’s compensation billing. Recently, we have gotten denials from some of the insurance carriers denying the assistant surgery due to "the surgeon must specify what specifically the assistant performed." We have never heard of this requirement, and the surgeries are always authorized for an assist. Additionally, these are codes that have the correct Medicare indicator to receive payment for an assist. I found a blog article from 2013 written by Marilyn Holley, CPC, CPC-I, RHIT, CHISP, (https://www.aapc.com/blog/25432-prom…rgery-payment/) that contained a sentence stating the physician must include these details in their report as well, however, she did not cite the guideline that would require specifics in the documentation of what the assistant did. Due to our recent denials, I was hoping for some help…Is there a requirement for the assistant’s actions to be specifically documented in the report? If so, what is the regulation and where is this stated?

Thank you in advance for the input!

Medical Billing and Coding Forum

Assistant Surgeon claim denial: considered inclusive …

In GYN surgery, the primary surgeon did multiple procedures. The assistant surgeon assisted with only one of those procedures. The procedure that had the assistant was considered inclusive of the other services done by the primary surgeon. Does the assistant surgeon have any standing for appeal? I have no administration over the claims or billing of the primary surgeon. The assistant surgeon is reaching out to me to see if there is anything he can do to get paid.

Medical Billing and Coding Forum

spine surgery for assistant surgeon

Hello I have a question we have been billing spine surgeries with 22804-80 22844-80 22214-80 22216-80 X 8 units are we allowed to get reimbursed for all of 8 units for assistant at surgery for cpt 22216? we are getting denials stating that we are only allow 1 unit since is under assistant surgeon. please let me know

Medical Billing and Coding Forum