Orthopedic Coding Alert

Question: Several orthopedic seminars have stated the proper coding for assistant surgeons as being one of two possibilities:

Bill full fee with proper modifier (-80, -81, -82) and let the carrier calculate the reduction for the assistant surgeons payment; or

Bill 25 to 30 percent of the primary surgeons fee.
Which is more appropriate?

Clifford J. Schob, M.D.
Millburn, NJ

Answer: Each approach is correct, depending upon the payers policy, as coding for assistant surgeons is a carrier-specific issue. For example, one practice in Grand Rapids, MI, bills Medicare the full primary surgeons fee, appending the appropriate modifier. Medicare reimburses 65 percent of the allowable and then it calculates 16 percent of that amount to determine the assistant surgeons reimbursement. But the practice knows that Michigan Workers Comp pays 13 percent of the allowable, while their primary HMO contract pays 20 percent of it. So, the practice bills these fractional amounts of the allowable to those particular payers at the outset. To receive proper reimbursement, the practice manager has confirmed the reduction amounts with each carrier in advance, and then has the clerk who posts the checks keep a close eye on the EOBs.

If you dont know what your non-Medicare payers will reimburse for assistant surgeons, a practice in South Carolina advised that 25 percent to 30 percent of the primary surgeons fee is a good place to start. However, you should monitor reimbursement closely. If you have payers that are reimbursing the full amount you request, then you should increase the proportion billed. If the payers arent reimbursing at 25 percent, then youll know by the payment what percentage to bill in the future.