Ob-Gyn Coding Alert

Certified surgical assistants (CSAs) often are employed in the ob/gyn operative setting to offer technical assistance for various procedures. But knowing when to use a CSA is not nearly so challenging as figuring out how to get reimbursed for their services. What is the proper, legal way to compensate the assistants and ensure that your practice receives fair reimbursement?

An assistant at surgery can be a physician, a non-physician health professional (i.e., physicians assistant, nurse practitioner or clinical nurse specialist), or a trained surgical technician who actively assists the physician in charge of the case in performing a procedure. But it is the distinction between these three types of assistants that determines coverage for the service and payment amounts. All payers will reimburse a physician to assist at surgery if the procedure in question warrants, under the payers guidelines, the use of an assistant. Many payers also will reimburse, but at a lower level, the services of non-physician health professionals who act as assistants at surgery. But Medicare and commercial insurers view a CSA or surgical technician very differently.

How Do CSAs Get Paid?

Emily Hill, PA-C, president of Hill & Associates, a physician reimbursement and coding firm in Wilmington, N.C., spells out some of the rules for reimbursement of assistants at surgery, as outlined in the Medicare Carriers Manual.

Payment is made for an assistant at surgery when one or more of the following conditions is met:

1. the medical necessity for an assistant has been demonstrated;

2. the surgery requires an assistant in more than 5 percent of the cases nationally; and

3. the assistance at surgery is performed in a hospital where no approved teaching program has been established.

When billing for an assistant at surgery, the primary surgeon reports the CPT code for the surgery without a modifier, and the assistant surgeon reports the same CPT code with modifier -80 (assistant surgeon) to indicate that he or she was an assistant surgeon. When the surgical assistant is a non-physician practitioner, however, the HCPCS modifier -AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) is used instead.

Medicare, on the other hand, Hill explains, does not reimburse CSAs because they are not considered accredited providers for services rendered. Most third-party payers also do not recognize these individuals as billable providers, and only a few will reimburse for their services at all, Hill adds.

Limited Methods of Reimbursement

Katie McClure, RHIA, is surgical coder at Southeastern Gynecologic Oncology, an outpatient surgery center with five physicians in Alpharetta, Ga. She says they use a CSA for such surgeries as hysterectomies and cancer debulking procedures. We have had several sources tell us we could bill for the assistants services under a physicians number, she says, and therefore get paid the full surgeons assistant fee, and the physician could then reimburse the CSA. McClure explains that, essentially, what has been recommended to them is that they bill for surgery using Physician A as the primary surgeon, and Physician B as the assistant. Then Physician B would reimburse the CSA. The recommendation raised some concerns regarding its legality.

Hill explains that using Physician Bs PIN (physician identification number) for the CSA to get paid is not appropriate. Since physician B did not actually act as the assistant at surgery, says Hill, using his/her number to bill for the services of the certified surgical assistant could be considered fraudulent, and you of course want to avoid even the appearance of this. She recommends that if the suggestion to bill using this method came from a third-party payer, you should request something in writing from the carrier to have as justification for doing so. At some point, says Hill, the carrier may decide that it should not have been reimbursing for the services of the CSA and request a refund. If you have documentation from the carrier stating that it was acceptable to bill for the CSA services using the provider number of a physician, you will have justification for appealing the refunding of the payments. Hill also recommends that the insurance carrier for the patient be called prior to the procedure being done to verify acceptance of the CSA as a reimbursable provider and the method to bill for his/her services.

Harry Stuber, MD, a solo practitioner ob/gyn working in Cookeville, Tenn., has another method for working with CSAs. I use a CSA in all major surgeries, says Stuber, and she in turn uses a billing service that specializes in reimbursement for first assistants. Stuber explains that the CSA succeeds in obtaining reimbursement in most cases and is satisfied with her compensation even after the billing company takes its percentage of her reimbursements. But the company does not bother to try to obtain reimbursement from Medicare, which will not pay for a CSA. When we know that Medicare or another carrier wont cover her services, says Stuber, I pay her $25 an hour out of my pocket. Its worth it to me to have the technical assistance in the operating room.

Practices should keep in mind that when a commercial carrier pays a CSA, the reimbursement rate is significantly lower than what an assistant surgeon is reimbursed with the -80 modifier and usually much below that paid to a non-physician health professional acting as an assistant. Most commercial carriers will not pay for anyone in the operating room other than the physician. A few carriers may have a special code or modifier to append to the surgical code to recognize and reimburse for a non-physician professional and/or CSA. Otherwise, the expectation is that the cost of the CSA will be built into the overhead of the practice, and the surgeon will reimburse the CSA from his or her own pocket.