Orthopedic Coding Alert

Think you know the correct modifier? It differs depending on the insurer

Physician assistants (PAs) often serve as first assistants during difficult orthopedic surgeries, but practices face needless denials because they don't know the appropriate modifiers or teaching-hospital regulations.

The following four expert-tested tips can help your practice nail down your PAreimbursement every time.

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

If the Medicare Physician Fee Schedule lists a "1" or a "9" in Column U ("ASST SURG"), you cannot report a surgical assistant's claim for that particular procedure. According to the 2004 fee schedule, therefore, you cannot report a surgical assist with the ankle fracture codes 27760-27810, among other procedures.

If the fee schedule lists a "2" in Column U, you can bill a surgical assist. For example, Medicare lists the elbow ligament repair codes 24340-24346 as payable for an assist.

If Column U bears a "0," your documentation will make or break your assistant's reimbursement odds. According to the policy of AdminaStar Federal (a Part B carrier in Indiana), when this column lists a zero, "this means payment for assistants at surgery cannot be paid unless supporting documentation is submitted to establish medical necessity." You should submit your operative report with these claims to demonstrate why the orthopedic surgeon required an assistant.

Medicare assigns the "0" indicator to the wrist arthro-tomy codes 25100-25105, so you should only bill for a surgical assistant during these procedures if the surgeon is certain that he can demonstrate medical necessity to the patient's insurer.

Suppose your orthopedic surgeon performs a tendon transfer at the elbow (24301, Muscle or tendon transfer, any type, upper arm or elbow, single [excluding 24320-24331]) and asks your PA to serve as first assistant. Your orthopedist reports 24301, and your PAreports 24301-80 (Assistant surgeon). Medicare pays the orthopedist's service but denies the PA's claim.

Your error: You should append modifier -AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to your surgical code when you bill Medicare for your PA's assist, says Patrick Cafferty, PA-C, MPAS, president and CEO of Neurosurgical Associates of Western Kentucky. "Modifier -80 is primarily used with other third-party payers," Cafferty says. "You should obtain clarification on this from the provider-relations representative at each third-party payer because many of them have different rules."

Remember: You should still append modifier -80 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 Medicare.

Although Medicare considers PAs covered providers in all hospitals, the surgical-assisting rules differ in teaching hospitals. "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.

Caveat: If a qualified resident isn't available to assist, however, Medicare will reimburse your PA's assist. For example, suppose your orthopedic surgeon performs an open guillotine forearm amputation on a Medicare patient in a teaching hospital. The hospital does not offer an orthopedic surgery residence training program, so your surgeon brings your practice's PA to assist him.

Your surgeon should report 25905 (Amputation, forearm, through radius and ulna; open, circular [guillotine]), and your PA should report 25905-AS.

"If this is a frequent occurrence," Nelson says, "the practice should notify the carrier that residents will not be available on a regular basis at that teaching hospital for orthopedic surgery, and as such, your practice will be frequently billing for a PAor physician to assist in that setting -- even though it is a teaching hospital."

Although Medicare generally holds firm to its guidelines, private payers may publish completely different rules for surgical assistants -- and some may follow Medicare's lead instead of forging their own paths.

Blue Cross and Blue Shield of Texas, for example, follows Medicare's guideline and requires that you append modifier -AS -- not modifier -80 -- to PAs'surgical assist claims.

Regence BlueShield Idaho expands allowable surgical assistants beyond PAs, nurse practitioners (NPs) and clinical nurse specialists (CNSs). 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, LPN (licensed practical nurse), DDS (doctor of dental surgery), and surgical tech."