Wiki assistant coding for orthopedics

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AHI123

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Hello,

our providers work with assistant surgeons all the time but we have been having issues getting Medicare to pay all codes that are suppose to be paid based on medical necessity. We are not sure what Medicare is wanting us to include in the patients Operative Report that will be enough to show medical necessity and get these claims paid!!! Our doctors do include in the beginning of their report that an assistant will be used and why, but even with that we have not been sucessful in getting them paid. some examples of codes we are having this issue with are 29877, 29881,20680,25606,64718. Based on Medicare guidelines these are payable codes with proof of Medical Necessity, BUT WHAT IS ENOUGH FOR THEM TO GET THESE PAID?WHAT ARE WE MISSING? if anyone out there has been sucessful in getting these paid i would appreciate your help :)
 
I have a question to you,, do you have resident/fellows working with you at the hospital that you are assisting in performing the surgeries? If so, then assistant surgeon is not necessary and CMS or any other insurance company will not pay.

The codes you have listed don't need assistant surgeon, they are pretty basic surgeries. You may have to call CMS and found out what exactly they are wanting from your practice as far as the op note.

Hope this helps.
 
I agree w campy. my doc can do 20680 all day long alone.they want you to tell them what was so above/beyond difficulty that the surgeon needed an assistant.

I can tell you that Medicare and other payors definition of "medical necessity" is different from a physician's definition of medical necessity. I have been told in numerous seminars that CMS's rule for medical necessity is a payment guideline NOT a clinical guideline. They are not saying you CAN'T use an assistant - they are saying they wont pay for it because you can normally remove a screw alone, and if you cannot remove it alone they want you to say why, specifically.
 
thank you for your response..we figured that was the case.just wanted to see if we were the only ones dealing with non payment. :(
 
We use the Med Assets program to check for CCI edits, modifier use, etc....all of the codes above state "assistant at surgery may NOT be paid"... I think that you would have a very hard time getting paid, even with tons of documentation.
 
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