If a provider assists in a c-section do they need separate documentation from the primary surgeon documenting their roll during the procedure or is the primary surgeon listing them as the assistant enough documentation to bill for a c-section assist?
My assistant surgeon is stating that the following documentation is enough for me to bill for her assist on a c-section:
Cesarean Section Procedure Note
Indications: Arrest of descent in 2nd stage
Pre-operative Diagnosis: G1P0 at 38w4d, medical induction of labor for cholestasis of pregnancy, prolonged rupture of membranes, arrest of descent in 2nd stage
Post-operative Diagnosis: Same, s/p PLTCS, viable female infant
Surgeon: Geoffrey S. Maly, MD
Assistants: Annika Maly, MD
Anesthesia: Epidural anesthesia
ASA Class: 1
Procedure Details
My assistant surgeon is stating that the following documentation is enough for me to bill for her assist on a c-section:
Cesarean Section Procedure Note
Indications: Arrest of descent in 2nd stage
Pre-operative Diagnosis: G1P0 at 38w4d, medical induction of labor for cholestasis of pregnancy, prolonged rupture of membranes, arrest of descent in 2nd stage
Post-operative Diagnosis: Same, s/p PLTCS, viable female infant
Surgeon: Geoffrey S. Maly, MD
Assistants: Annika Maly, MD
Anesthesia: Epidural anesthesia
ASA Class: 1
Procedure Details