Neurosurgery Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: In the past, I've always reported modifier -80 for a certified PAin the operating room. Recently, however, I've been instructed that modifier -81 is correct. Which code is correct?

Delaware Subscriber

Answer: The answer depends primarily on your payer. Modifier -80 (Assistant surgeon) describes a second physician in the operating room who acts as an extra pair of hands to assist the primary surgeon. A common example is when an orthopedic surgeon and a neurosurgeon work together during placement of spinal instrumentation (for example, 22842, Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments). Use extra caution when reporting modifier -80 for a physician assistant (PA). Technically, only a physician fully licensed to practice medicine may report modifier -80. If the payer agrees to modifier -80 for a PA or other nonphysician practitioner (NPP), be sure to get the recommendation in writing in the event of an audit or retrospective review.

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. The absence of clarity causes payers to interpret modifier -81 differently. Some payers will allow this modifier for midlevel assistants such as PAs, while others do not use it at all or use it to report a second physician in the operating room for a small, selective portion of a particular procedure. Once again, if the payer agrees to allow you to use modifier -81 for NPPs, get the recommendation in writing.

For Medicare, the only appropriate modifier for an NPP in the operating room is modifier -AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery). Although Medicare will reimburse for the services of a clinical nurse specialist, physician assistant and nurse practitioner as assistants at surgery, it will not reimburse for surgical assistants such as registered nurse first assists, orthopedic physician assistants, licensed practical nurses and certified surgical technologists.

The PA assisting at surgery must have a Medicare (or Medicaid) provider number to bill for these services. Generally, the PA will also submit a claim with a copy of the operative report to describe how he or she assisted in the operating room.