Neurosurgery Coding Alert

In this case, two surgeons are required to complete the reconstruction. Surgeon A undertakes the vertebral resection, while B decompresses the spinal cord. Surgeon A performs the arthrodesis and, with surgeon B's assistance, places the instrumentation. Coding should appear as follows:

Surgeon A
63087-62 
63088-62
22556-51 (Multiple procedures)
22585 x 2
22846

Surgeon B
63087-62
63088-62
22846-80

Because each surgeon performs a distinct portion of the vertebral corpectomy (the resection and decompression, respectively), they report 63087 and 63088 as co-surgeons. Surgeon A reports 22556 and 22585 x 2 for the arthrodesis and 22846 for instrumentation. Because Surgeon B assisted during placement of instrumentation, he reports 22846 also, but with modifier -80 appended.

Note: For complete information on modifier -62, see Neurosurgery Coding Alert, September 2002.

Modifier -81 specifies "minimum" assistant surgeon, but neither CPT nor CMS provides definitive guidelines to help physicians and coders distinguish a minimum assistant from a "regular" assistant as described by modifier -80. This absence of clarity causes payers to interpret modifier -81 differently.

"I believe that the original intent of the modifier [-81] was to offer physicians a way to bill when they only came in and helped with a small portion of the surgery but didn't stay and assist for the whole procedure," says Marcella Bucknam, CPC, HIM program coordinator at Clarkson College in Omaha, Neb. "Now, however, modifier -81 is most often used when the assistant is not another surgeon especially with midlevel assistants.

"At this time, I don't know of any insurers who like the modifier except for a few that want it when a nonphysician assists in the operating room," Bucknam continues. "If the insurer pays, the rate for -81 is usually 10 percent of the full surgeon's fee." Note, however, that other insurers will reimburse for surgical assistants, physician assistants (PAs) and other nonphysician practitioners acting as assistants at surgery with modifier -80. But technically, only a physician fully licensed to practice medicine may report modifier -80. Therefore, if a payer advises you over the phone to use modifier -80, be sure you obtain verification in writing to protect yourself.

"We recommend talking to the individual insurer to find out what its rules are for submitting claims," says Michael Powe, director of reimbursement for the American Academy of Physician Assistants. "It is important to see if there are specific enrollment criteria and credentialing requirements for a PA working in the surgical unit. That should eliminate any of the confusion on how to submit a claim and what modifier to use."

Unlike some private payers, Medicare will allow only physicians to report modifier -80. "Medicare has eliminated all of its HCPCS modifiers for PAs except the -AS modifier for first assisting," Powe says.

Specifically, Medicare will reimburse for the services of a clinical nurse specialist, physician assistant and nurse practitioner as assistants at surgery. Medicare will not reimburse for surgical assistants such as registered nurse first assists, orthopedic physician assistants, licensed practical nurses and certified surgical technologists. Powe adds that few non-Medicare carriers use the -AS modifier.

For Medicare, the PA assisting at surgery must have a Medicare (or Medicaid) provider number to bill for these services. "Most times, the PA also will submit a claim with a copy of the operative report, which states quite clearly how he or she assisted in the operating room," Powe says. Calling a carrier to get preauthorization whenever using a PA in surgery can also aid reimbursement.

Use of modifier -82 is limited to teaching hospitals and is appropriate only if a qualified resident is not available to assist. "In general," says Nancy Hughes, vice president of communications and information services for the American Academy of Physician Assistants (AAPA), a national professional society representing PAs, "payment is not made for first assisting when the service is provided in a teaching hospital that has a training program related to the particular surgical procedure and a qualified resident is available. But, if the teaching hospital has no qualified resident available or no teaching program related to the particular medical specialty required for the procedure, or if the primary surgeon has an across-the-board policy of not using residents, Medicare will cover the services of a PA first assistant."

Payers will not reimburse for assistants at surgery in all cases, regardless of the modifier(s) appended to the claim. For Medicare, services rendered by an assistant at surgery are eligible for reimbursement only when national claims data indicate the procedure necessitated an assistant in at least 5 percent of the claims based on a national average. Other payers follow similar guidelines.

Therefore, prior to billing for an assistant at surgery using modifiers -80, -81, -82 or -AS, be sure to check column T of the Physician Fee Schedule to be certain that an assistant is allowable. Only procedures with a 2 in column T will be paid routinely. For those procedures that include a 0 in column T, Medicare restricts payment for assistants at surgery unless supporting documentation is submitted to establish medical necessity. A 1 indicates that an assistant at surgery will never be paid, while a 9 indicates that the concept does not apply.