Ob-Gyn Coding Alert

Question: When is it appropriate to bill for co-surgeons, versus surgical assistants?

Florida Subscriber

Answer: It is appropriate to bill for co-surgeons when the skills of two surgeons are needed to perform a procedure described by a single CPT code (e.g., 58152, total abdominal hysterectomy with or without removal of tube[s], with or without removal of ovary[s]; with colpo-urethrocystopexy [e.g., MMK, Burch] or 58200, total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]).

Assistants at surgery, on the other hand, do not perform a surgical procedure; rather, they hold retractors, suction and suture (they act as a second pair of hands to the surgeon). Each co-surgeon writes his or her own operative note describing what he or she did, and each may also be involved in both the pre- or postoperative care. An assistant does not describe what he or she does and will only be mentioned by name in the summary as having been present. Not all surgical procedures warrant co-surgeons because the procedures may be minor or simple. For instance, you would not expect to have co-surgeons for a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) or a vaginal hysterectomy, but you might need an assistant during these surgeries.