Wiki Assistant Surgeon who is of same specialty

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txgirl45

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Good Morning I work for a large ortho practice here in Texas and we have a DPM who assisted another DPM on surgeries and insurance is denying claims. They are all coming back denied even though codes were all checked before billing and
were billed with mod 80. Do you all have any insight on where I can find information on if someone can assist on a surgery who is of the same specialty of primary surgeon? Thanks!
 
What codes were they? Does the payer have it's own assistant-at-surgery billing list? Are you sure both claims were billed correctly? I have seen where someone accidentally put the 80 on both or didn't drop the price on the assistant claim. Because the same fee was on the primary and the assistant one got denied since they saw as a dupe. Not saying that's a correct denial, but it happens if you don't cut the fee.
 
I billed the primary surgeon correctly. Billed Assistant surgeon with modifier 80 and reduced charge. I checked all the codes for payment restrictions first. It was for Medicare and BCBS only. Are there restrictions on a DPM assisting another DPM or provider of same specialty.
 
Does the procedure allow reimbursement for an assistant surgeon? You can look up the assistant surgeon indicator for the CPT on the Medicare fee schedule.

The meanings of the indicators on the fee schedule are:

0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.

1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery may not be paid.

2 = Payment restriction for assistants at surgery don’t apply to this procedure. Assistants at surgery may be paid.

9 = Concept doesn’t apply.
 
There are more questions here.
Was it only one case or multiple? Is it every case that this provider assists on?
What were the codes? What is the denial reason. Are they definitely denied and not just rejected at the clearinghouse level?
Is this related to a teaching facility at all?
When you say, "insurance is denying claims. They are all coming back denied" does this mean both the primary claims and the assistant?
It doesn't matter if they are the same specialty. That's not why they are denying. There has to be some other reason, it's possible this is not the correct question.
 
yes it was multiple cases. There are several codes. The denial reason is that an assistant surgeon can not be of same specialty as primary surgeon. Primary claims paid. Only assistant surgeon claims denied.
 
Who denied it Medicare or Blue Cross? That sounds more like a modifier 62 denial. Has the payer been contacted about it? If it's that many it sounds like more data analytics needs to be done and looked into more.

I could have sworn I read somewhere there was an issue where claims were denying incorrectly for this but now I cannot remember which payer, etc. Is it only one time frame yet other claims out of that time are paid?
 
It was denied by both Medicare and Blue Cross. They are saying an assistant surgeon cannot be of same specialty as primary. They are both DPM's.
 
That's a co-surgery type denial. Thatwould normally be seen if a 62 was appended and both MDs are of the same specialty.

Either these have a 62 modifier incorrectly where it should be 80, the codes do not allow assistant at surgery or co-surgery, or there was a claim issue and/or processing error with that MAC which you would need to look into. If it was Medicare primary of course Anthem secondary would also deny. If Anthem was primary and doing the same thing it has to be an incorrect 62.
It could be incorrect denials from a payer, that does happen. Have you contacted Novitas? You'll have to have someone figure out the impacted claims, time frame, and codes, etc. and compare to other claims outside of the time frame with the same codes and providers to figure it out. It could also be something with a provider's credentialing. Are claims with these providers in other time periods, paid, etc?
I have seen where a practice management system is incorrectly updating/flipping modifiers and other items like changing a CPT to a G code or auto-changing items on the claim but it looks correct when entered by a person into a billing screen.

If your group is that big, you should have a data analytics person or someone higher up in the rev cycle that can help with this. They would need to know things like the # of impacted claims, time frame, providers involved, the codes, and the exact denial reason/remark code. If it's that big of a problem someone in the rev cycle higher up or the provider would have noticed depending on how long it's been going on. It sounds like if you are a staff coder, maybe you need to bring it to a supervisor or someone higher up for team help. When you say, "insurance is denying claims. They are all coming back denied" what does "all" mean? It needs to be quantified. If it was all of their surgical cases they would be having a freakout, especially if their paid by RVUs.
 
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