Urology Coding Alert

Learn when 80 applies versus 81, 82, and other possibilities.

Surgical coding can always pose a challenge, but add an assistant surgeon in the mix, and you’ll find yourself dealing with an entirely new set of questions to address. You have three modifiers from which to choose when reporting the services of an assistant surgeon, but the most common is modifier 80 (Assistant surgeon). Check out our experts’ advice for correctly reporting modifier 80 to get the payment your urologist deserves.

Know Why You’ll See an Assistant on the Case

The primary surgeon may use an assistant surgeon for several reasons, such as when the procedure or the patient’s condition is more complex than the norm. The assistant surgeon works under the direct supervision of the principal surgeon and is often in the same specialty as the principal surgeon.

Sometimes the urologist you code for might act as the primary surgeon on the case; sometimes he or she might act as the assistant surgeon.

According to Medicare guidelines, “an assistant at surgery must actively assist when a physician performs a Medicare covered surgical procedure. This necessarily entails that the assistant be involved in the actual performance of the procedure, not simply in other, ancillary services.”

Medicare guidelines continue, “Since an assistant would, thus, be occupied during the surgical procedure, the assistant would not be available to perform (and thus, could not bill for) another surgical procedure during the same time period.”

When an assistant surgeon assists an operating or principal surgeon during an entire procedure, append modifier 80 to the surgical code.

Important: Do not confuse modifier 80 with modifier 62 (Two surgeons), which describes two physicians both acting as co-surgeons or primary surgeons for one procedure.

Add Modifier AS for Certain Cases

Medicare will only pay for a surgical assistant when the procedure performed is authorized for an assistant, and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP), or a clinical nurse specialist (CNS).

When a PA, NP, or a CNS assists at surgery, attach modifier -AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to the surgical code along with modifier 80.  

Without modifier -AS, modifiers 80, 81, and 82 indicate that a physician was the surgical assistant. Claims you submit that include modifier -AS without modifier 80, 81, or 82 will be returned to you.

Caution: Many commercial insurers follow Medicare’s rules, but not all do. Be sure to query each of your payers to find out their policies on billing for surgical assistants. They may want only the modifier -AS, or they may not recognize it at all.

Note: Modifier-81 (Minimum assistant surgeon) is rarely used today in urological coding, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Even so, it’s still good practice to be aware of the modifier and its purpose.

Check the Fee Schedule for Guidelines

Before billing for an assistant at surgery using modifier 80 or AS, double check the ASST SURG column of the Medicare Physician Fee Schedule (MPFS) to verify that the procedure(s) allows an assistant.

Payers will not reimburse you for assistants at surgery in all cases, regardless of the modifier(s) you attach to the claim. For Medicare, assistant at surgery services are eligible for reimbursement only when national claims data indicates the procedure would require an assistant in at least 5 percent of the claims based on a national average, according to Medicare guidelines.

“Many carriers create their own rules that determine which practitioners can bill as assistant surgeons,” says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, consulting director of education for The Coding Institute in Naples, Fla.

Remember these designations in the ASST SURG column:

• A “0” indicates that Medicare will allow payment (upon satisfactory review) for an assistant at surgery if you submit supporting documentation to establish medical necessity.
• A “1” tells you that an assistant at surgery will never be paid. You should never apply modifier 80 or AS to these codes. » »
• A “2” means that Medicare will routinely pay for the procedure in conjunction with an assistant surgeon. Append modifier 80 and/or AS to these codes to indicate that an assistant surgeon was involved with the case.
• A “9” indicates that the assisted surgery concept does not apply. You should never attach modifier 80 or AS to these codes. Many of the N status or non-covered codes carry a 9 in the assistant at surgery column.

Resource: You can download the Physician Fee Schedule Relative Value File from the Medicare Web site, www.cms.hhs.gov. From the home page, search for “PFS Relative Value File,” and select the first search result. Be sure to download the most recent file available.

Document the Details

If your urologist acts as a “second pair of hands” in the operating room, assisting the primary surgeon, you should append modifier 80 to the procedure code. An assistant surgeon does not have to provide his own operative notes, but the primary surgeon should note the second urologist’s name as the assistant surgeon in his operative report.

Be aware that payment is much less for an assistant surgeon than for a co-surgeon. For an assistant surgeon, Medicare allows 16 percent of the total allowed amount, and commercial payers vary from 16 to 50 percent of the primary allowed amount. Coding experts advise against billing the full global fee for the assistant’s fee because this may confuse the carrier as to who was the surgeon and who was the assistant, and often one surgeon remains unpaid.

Example: Your urologist assists another urologist in performing a radical nephrectomy, 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). Your urologist would report 50230-80 as the assistant surgeon.

Final point: Keep in mind that each physician must document his own part of the procedure when more that one provider is involved, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Ferragamo agrees. “Each physician must dictate separately his part of the operative report in detail and indicate what the other physician performed as his part of the operation,” he says. That documentation helps you report things correctly from a coding standpoint and also explains the situation to the insurer.