Medicare Compliance & Reimbursement

Warning: Assistant surgeon rules differ between carriers, and change in teaching hospitals Insurers pay an additional fee for assistant surgeons, and therefore review assistant surgeon claims carefully. But you can keep your assistant surgeon coding on the straight and narrow by following a few quick tips. "Many carriers create their own rules that determine which practitioners can bill as assistant surgeons," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions. "You can review the Medicare fee schedule to find out which surgeries are billable with assistant surgeons," she says. Find co-surgeon info in column U: Not every CPT code is eligible for reimbursement with an assistant surgeon, and you can determine which codes are billable by looking at column "U" of the Fee Schedule. A "2" in column U means that Medicare will pay for an assistant surgeon without further review (such cases are rare). A "1" means that Medicare will pay for an assistant with explanatory documentation. A "0" means that Medicare will never pay for an assistant surgeon, and a "9" means that the concept of assisted surgery does not apply. Example: In the operating room, the surgeon debrides necrotizing soft tissue of the external genitalia and abdominal wall, including fascial closure (11006, Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection). Because of the procedure's relative complexity in this case, the surgeon requests another surgeon to serve as a "second pair of hands" during the operation. In this case, you may bill for the assistant surgeon, as long as you supply supporting documentation, because the fee schedule assigns 11006 a "1" in column U. Keep teaching physician rules in mind: Before you bill for an assistant surgeon's work, "check to see if there is a residency program in surgery," suggests Charlotte T. Tweed, RHIA, CPC, with the Florida Hospital Department of Medical Education. "If the answer is yes, then an assistant fee can only be charged when there is not a qualified resident available for the surgery," she says. "Our physicians note in the operative report there is not a qualified resident available when that stipulation is met and there is an assistant other than a resident for the procedure." Remember: Most carriers reimburse 16 percent of the surgical fee for the assistant surgeon, in addition to 100 percent reimbursement for the primary surgeon.