Neurosurgery Coding Alert

Neurosurgeons undertaking time-intensive procedures can often benefit from a physician assistant (PA) serving as a surgical first assistant. However, insurer guidelines vary and receiving reimbursement is a challenge. Communicating with payers, obtaining preauthorization and appending the proper modifiers will reduce reimbursement headaches.
  
What and How Much
PAs are licensed healthcare professionals who may, under a physician's supervision, practice medicine in any setting (e.g., office, clinic or hospital), says Barbara Johnson, CPC, a coding expert with Loma Linda University Medical Group in California. In most cases PAs can, for instance, take a patient's history, perform a physical exam, order and interpret tests, provide patient follow-up (including hospital rounds), and assist during surgery. As such, a PA can allow the neurosurgeon to allot his or her time more efficiently.
 
A PA bills for his or her services with a personal identification number (PIN). Generally, reimbursement is 85 percent of the rate paid to a physician in the same circumstances, Johnson says. Reimbursement for physicians serving as surgical first assistants varies from 16 to 20 percent of the primary surgeon's fee, depending on the payer. For example, if the insurer pays a physician first surgical assistant 20 percent of the primary surgeon's fee of $100, or $20, a PA serving as first assistant for the same surgery would receive $17 ($20 x .85%).
 
Note: Services provided by a PA billing under his or her own PIN are distinct from services provided "incident to" physician services. Incident to services are billed under the physician's PIN, are reimbursed at 100 percent of the usual rate, and are governed by separate guidelines.
 
For more information on incident to billing, see Neurosurgery Coding Alert, December 2001, "Focus on ABNs and Incident To." 
When Is a Surgical Assistant Appropriate?
Although surgical first assistants are useful in many neurosurgical procedures, including diskectomies, laminectomies, craniectomies and others, they are not appropriate for every surgery, Johnson notes. Section 15016 of the Medicare Carriers Manual specifies that an assistant at surgery will not be reimbursed "in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available." Only under special circumstances, i.e., a qualified resident is not available or the primary surgeon never uses residents, will Medicare pay for an assistant at surgery at a teaching hospital (see information on modifier -82, below).
 
Although national Medicare policy recognizes the role of licensed PAs as assistants at surgery, state practice laws vary. In some states, PAs cannot bill for their services at all, says Susan Callaway, CPC, CPS-C, an independent coding and reimbursement specialist in North Augusta, S.C. In addition, payers private and Medicare may specify their own guidelines for assistants at surgery. [...]