Primary Care Coding Alert

About one of every four family physicians serves as an assistant at surgery, according to the American Academy of Family Physicians (AAFP) 2001 practice profile survey. To be reimbursed for the surgery, the physician's office must use the proper procedure code, append a modifier and, in some cases, document the medical reason an assistant was needed.
 
The assisting surgeon uses the same procedure code as the primary surgeon and appends modifier -80 (assistant surgeon) or uses the separate five-digit modifier 09980, says Kent Moore, manager of Health Care Financing and Delivery Systems for the AAFP. Modifier -80 applies when the assistant surgeon is present for all of, or a substantial portion of, an operation.
 
Two other modifiers apply less frequently:

 

09981 or -81 (minimum assistant surgeon) is used when the assistant provides minimal assistance to a surgeon for a relatively short time.

 

09982 or -82 (assistant surgeon [when qualified resident surgeon not available]) usually applies to teaching hospitals and is used when a qualified medical resident, who typically performs the assistant's role, is unavailable.

Probably the most common procedure when the family physician assists is a Cesarean section, Moore says. He notes that the AAFP practice profile survey found that 22.3 percent of family physicians perform routine obstetrical deliveries in hospitals. When a C-section becomes necessary, the family physician may call in an ob/gyn because the family physician lacks surgical privileges or is not comfortable performing surgery, Moore says.
 
Carol Sissom, CPC, senior consultant at the Indianapolis-based Health Care Economics Inc., says the family physician often calls in an obstetrician when a fetus has complications, such as a breech first position as labor begins. Typically the ob/gyn performs the C-section, while the family physician assists, Sissom says.
 
In this scenario, the family physician's office uses 59514 (Cesarean delivery only) appended with modifier -80 and a diagnosis of 652.21 (breech presentation without mention of version; delivered, with or without mention of antepartum condition), Sissom says. Modifier -80 indicates that the assistant was actively involved in the surgery. Use modifier -81 only if the family physician plays a minimal role, such as applying a clamp if there is bleeding, Sissom says.
 
"If the assistant actually gets hands-on either opening the abdomen or helping remove the baby you would want to use modifier -80," Sissom says.
 
With many carriers, it isn't necessary to document a complication requiring an assistant's help at a C-section. Because Medicare includes C-sections for surgeries that don't require documentation that an assistant helped with  a complication, many insurance companies will also cover an assistant for C-sections, says Mark Painter, vice president of reimbursement and coding information at Physician Reimbursement Systems in Denver.
 
However, some carriers may require you to document  why the assistant was needed. Sissom suggests that the physician's office should document complicating factors in case the information is requested. In the example above, the breech presentation is a complication, she says.

In addition to assisting at C-sections, family physicians in rural areas may also assist in other surgeries, Moore says. Rural areas may have only one surgeon, who calls on a family physician to assist when necessary. Even in midsize cities, the family physician may be asked to assist with surgery in the event of a severe accident involving injuries to many people, Sissom says.
 
Many carriers base their assistant-surgeon policies on Medicare's payment policies, Painter says. If the surgery performed is not one for which Medicare will usually pay for an assistant, the carrier will likely require documentation of complications creating a need for an assistant. The complications typically need to be clinical, such as obesity or history of problems during previous surgeries, Painter says. The carrier may also request records of the surgery to document the need for an assistant.
 
"That's very common when there's an assistant at surgery," she says. "They want to see why the assistant was needed, especially when another specialty is involved."
 
If the complications are unusual, the physician's office should also submit a written report documenting the need.  Sissom gives an example: A toddler with birth defects is referred by a family physician to a specialist for a comprehensive and painful hearing test. The procedure cannot be performed because the child is agitated. The child is then sedated, and the family physician is asked to assist with the monitoring following conscious sedation. The family physician's assistant role is coded 92585 (auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive) and appended with modifier -80. The complicating factors, which should be documented, are the child's birth defects and agitation, Sissom says.