Wiki Assistant Surgeon Modifier 81/AS

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meganbruce

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We are having a conflict at our office. I tell the surgeons I code for that if they use an assistant surgeon, they must dictate what the assistant surgeon did during the surgery. We have several doctors that are stating that they just need to state that an assistant was used, that they don't need the full description of the services performed by the assistant.

Is there and article from the AAPC regarding this? Who is correct?

thanks for any help on this matter!
 
when there is a co-surgeon then the doctor will give a brief summary of the co surgeons part of the surgery and they will also note that a separate report will be dictated by the co surgeon. When a physician assistant is used for a surgical assistant you just need to note their name and that they assisted, the same for a physician who assist. The assistant surgeon should give you the same codes as the lead surgeon with the 80 or 81 modifier, the same for the physician assistant with the AS modifier.
 
Assistant surgeons

My doctor assists, and is assisted, on many surgeries, and he has always stated that the primary doctor who does the dictation does not have to specifically state what duties the assistant did. They work together on the procedure. He says that if they begin to require specifics as to what each doctor did during the op, it could become a matter of "nit-picking", as they are working as a team.
 
meganbruce said:
We are having a conflict at our office. I tell the surgeons I code for that if they use an assistant surgeon, they must dictate what the assistant surgeon did during the surgery. We have several doctors that are stating that they just need to state that an assistant was used, that they don't need the full description of the services performed by the assistant.

Is there and article from the AAPC regarding this? Who is correct?

thanks for any help on this matter!
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There is an article in the Coding Edge, January 2008. As for the documentation, it is necessary. Carriers will use this as a way to avoid paying for the assistant if the operative note does not support the need for their presence.
 
All that is needed is that the primary surgeon dictates the procedure and indicates "WE" as surgeons and also the assist's name must be indicated on the operative note.
 
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