Neurosurgery Coding Alert

Avoid modifier AS in teaching hospitals

If your surgeon uses a physician assistant (PA) to help out during surgery, you'll want to know the payer you're dealing with before appending either modifier AS or modifier 80 to your claim.

Here are four tips to be sure your PA won't miss out on the reimbursement she deserves.

Step 1: Check the Fee Schedule

Before billing a PA as a surgical first assistant, you must know if the insurer will reimburse for the PA's services. For Medicare, the easiest way to do this is to consult the Physician Fee Schedule Database.

"Each year, as part of the Physician Fee Schedule, Medicare publishes those procedures for which they approve technical surgical assisting by a physician, physician assistant, nurse practitioner, or clinical nurse specialist," says Ron L. Nelson, PA-C, president and chief executive officer of Health Service Associates Inc., a healthcare consulting firm based in Fremont, Mich.

Look for a 2 in column "U": If the fee schedule lists a "2" in Column U ("ASST SURG"), you can bill for a first surgical assistant.

Likewise, you can report surgical assist if column U contains a "0," but your documentation becomes more important. Typical Medicare policy dictates that when column U lists a 0, reimbursement "for assistants at surgery cannot be paid unless supporting documentation is submitted to establish medical necessity."

A "1" or "9" means no luck: If the fee schedule lists a "1" or a "9" in Column U, you cannot gain payment for a surgical assistant for that procedure.

Tip: The 2005 physician fee schedule database is available as a free download at the CMS Web site www.cms.hhs.gov.

Step 2: Append AS for Medicare Patients

The PA serving as a surgery assistant reports the same CPT codes as the primary surgeon. To indicate that a PA provided the services, however, you should append modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to claims for Medicare carriers and some third-party payers, says Betty Carpenter, CCS-P, coding and compliance manager for a Grand Rapids, Mich., provider.

Example: The PA serves as surgical first assistant during a diskectomy for a Medicare patient. The primary surgeon claims 63075 (Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace). The PA reports 63075-AS under his own PIN.

Document: The operative report should explain exactly how the PA assisted in the operating room. Also, a form letter, included with the claim and explaining why the surgeon needed the PA's assistance, will help reduce claim delays and denials.

Remember: You should still append modifier 80 (Assistant surgeon) to your Medicare patient's surgical assist claims if a physician performs the assist. Modifier AS only applies when you bill nonphysician practitioner claims to a Medicare carrier, although some non-Medicare payers follow different guidelines.

Step 3: Use Caution in Teaching Hospitals 
 
Except in unusual circumstances, you shouldn't report a PA surgical first assist in a teaching hospital.
 
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."

"Any hospital with an approved residency program cannot have other parties - such as other physicians or PAs - provide services and bill Medicare, because Medicare has already reimbursed the hospital via its residence funding," Nelson says.

Exception: If a qualified resident isn't available to assist, Medicare will reimburse your PA's assist, but you must document the circumstances.
 
Don't forget: Carrier preference reigns when it comes to modifiers. Many payers prefer that you append modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) when there's no resident surgeon available to assist, says Leslie Follebout, CPC, coding department supervisor at Peninsula Orthopaedic Associates PA in Salisbury, Md.

Step 4: Seek Instructions From Private Payers

Although Medicare generally holds firm to its guidelines, private payers may publish completely different rules for surgical assistants.

"Some companies will not accept the HCPCS modifier AS, and some will," Follebout says. "Medicare always wants the AS, but when we submit our claims to Blue Cross/Blue Shield, for instance, we must use modifier 80."

Blue Cross Blue Shield of Texas, in contrast, follows Medicare guideline and requires that you append modifier AS, not modifier 80, to most PAs' surgical assist claims.

And, Regence BlueShield of Idaho expands allowable surgical assistants beyond PAs, nurse practitioners (NP) and clinical nurse specialists (CNS). The carrier's policy states, "Provider specialties eligible for modifier AS include CNS, PA, CRNFA (certified registered nurse first assistant), RNFA (registered nurse first assistant), NP [and] LPN (licensed practical nurse)."

Best practice: Query your top-20 payers regarding how you should report PAs' assists, create a file for each payer and keep their modifier preferences with each payer's contract.

Bonus tip: As a precaution, especially for non-Medicare payers, you may want to obtain preauthorization before billing a PA for surgical first assist.
 
Be sure to get the payer's recommendations in writing, because this will greatly reduce delays and denials and provide you with essential backup in the event of an audit.