dballard2004
True Blue
I have specific question on what documentation is required to code/bill separately for an assistant surgeon with modifier 80...
My understanding is that the primary surgeon has to document in the op note the reason why an assistant surgeon was needed (medical necessity) and the services provided by the assistant during the procedure. I have a breast surgeon who performed a left axillary dissection with an assistant surgeon. The note just states....
"Dr. XXXX assisted with the case due to prior scarring to decrease the operative time and preserve the nerve function."
Is this sufficient to code/bill for the assistant surgeon? I say no since there is no more detail as to what the assistant actually did, but I have a coder who states this is correct documentation to code the assistant.
Thoughts/Insights please? Thanks.
My understanding is that the primary surgeon has to document in the op note the reason why an assistant surgeon was needed (medical necessity) and the services provided by the assistant during the procedure. I have a breast surgeon who performed a left axillary dissection with an assistant surgeon. The note just states....
"Dr. XXXX assisted with the case due to prior scarring to decrease the operative time and preserve the nerve function."
Is this sufficient to code/bill for the assistant surgeon? I say no since there is no more detail as to what the assistant actually did, but I have a coder who states this is correct documentation to code the assistant.
Thoughts/Insights please? Thanks.