Wiki Codes that do not allow an assistant surgeon

[tamale79]

Hello,
I have a question about the wording in the CMS guidelines about charging for an assistant surgeon. Page 29 (https://www.cms.gov/files/document/2020-physician-fee-schedule-guide.pdf) states, "1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery may not be paid."
I am interpreting this as - Do NOT charge an assistant for this code, it is not legally allowed. My billing manager and the drs are interpreting that "may" as - it might not get paid but try it.
Does anyone have any non-ambiguous documentation that I could refer to??
Thank you!

 

[thomas7331]

The CMS payment indicators are part of the reimbursement policy - they are not coding guidelines or regulations. Other payers may or may not follow these rules.

I would recommend caution against billing these services because doing so can potentially create overpayments (if claims are paid in error), inflate the A/R and create extra work for the practice, and might even open your providers to red flags for audits or accusations of billing medically unnecessary services. But I'm pretty sure that it is not illegal and, as long as supported by documentation, it is not against coding guidelines to bill these.

 

[jkyles]

You're correct and I don't think the language is ambiguous. They should look at the definition for 2 "Payment restriction for assistants at surgery don’t apply to this procedure. Assistants at surgery may be paid."

 

[csperoni]

Basically, the assistant at surgery indicators are:
0 - will only be paid with medical necessity
1 - never allowed
2 - always allowed
Most of the instructions from CMS are really to the MACs. So CMS is telling the MAC "Assistants at surgery may not be paid" as in the MACs are not permitted to pay for it.

As Thomas mentioned, these are CMS policies. Although I don't recall ever seeing a commercial carrier willing to pay for an assist that Medicare would not.

From my experience, practices either do not code these at all, or code internally only (do not bill to insurance) for tracking metrics.