Wiki Documentation Requirement for Assistant at C/S

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ELBrock

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Hello!
Our practice has two MD's and two CNM's.
Often, the CNM's will assist during Cesarean Deliveries.
The provider will list the assistant CNM in the heading of the operative report simply as:
Assistant: CNM's name
The remainder of the operative report does not mention the CNM again.
I am in the process of billing the CNM's claim for assisting during the C/S with modifier "AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery."
I am looking to use modifier AS over modifier 80, as modifier 80 is specific for an Assistant Surgeon, which the CNM's are not.
According to the CMS HCPC Code Set guidelines, modifier AS is to be billed a specific way:
1) Under the operating physicians NPI, not the assistants NPI
2) "The main surgeon should clearly specify in the medical record the medical necessity for utilizing the service of an assistant."

Our MD's are disputing that they need to document why an assistant was needed during the Cesarean Delivery. Even after showing them CMS guidelines on the documentation requirement, they state they have never had a denial or request before for not having a statement on why an assistant is medically necessary. They want me to bill the claim and just let them know if it denies for that, because they say it will not.
Does anyone have any information on if Cesarean Sections are specifically excluded from this requirement? Or am I misinterpreting CMS' guideline here. Could CMS be meaning that the Operative Report just has to have documentation that substantiates the need for an assistant, rather than an actual statement on exactly why they needed one?
 
I can't speak specifically to CMS requirements, but I can tell you that TRICARE for one is denying all assists that don't specify the medical necessity of the assistant and what they did. However so far there is not requirement in our organization for doctors to specify more than the name of the assist, unless it's a teaching facility where they need to state a qualified resident wasn't available. I have not seen any Medicare denials on assists so far - also we bill under the assist (CNM, NP, etc). For assists with an RNFA, etc, where we need to bill under the operating physician, these are often denied as duplicates.
 
I agree with the above, I have not seen payers enforce a requirement for specific documentation for an assistant or deny assistant claims due to specific medical necessity for an assistant not being documented in the procedure note. As a general rule, for procedures that routinely involve an assistant, it has been sufficient to simply document the name and credentials of the assistant in the record. But some physicians do include a description of what the assistant actually did during the procedure, and I think this is a good practice that could protect you in the event of an audit, and it's something that could be easily added into their template.

I'm a little puzzled in what you are saying about the CMS requiring the AS modifier to be billed by the operating physician - I think that guidance may be out of date. The assistant's service should be billed under their own NPI. Especially if the procedure is performed in a facility setting, it is inappropriate to bill any professional services as 'incident to' the physician's.
 
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thomas7331 said:
I agree with the above, I have not seen payers enforce a requirement for specific documentation for an assistant or deny assistant claims due to specific medical necessity for an assistant not being documented in the procedure note. As a general rule, for procedures that routinely involve an assistant, it has been sufficient to simply document the name and credentials of the assistant in the record. But some physicians do include a description of what the assistant actually did during the procedure, and I think this is a good practice that could protect you in the event of an audit, and it's something that could be easily added into their template.

I'm a little puzzled in what you are saying about the CMS requiring the AS modifier to be billed by the operating physician - I think that guidance may be out of date. The assistant's service should be billed under their own NPI. Especially if the procedure is performed in a facility setting, it is inappropriate to bill any professional services as 'incident to' the physician's.
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ELBrock said:
Hello!
Our practice has two MD's and two CNM's.
Often, the CNM's will assist during Cesarean Deliveries.
The provider will list the assistant CNM in the heading of the operative report simply as:
Assistant: CNM's name
The remainder of the operative report does not mention the CNM again.
I am in the process of billing the CNM's claim for assisting during the C/S with modifier "AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery."
I am looking to use modifier AS over modifier 80, as modifier 80 is specific for an Assistant Surgeon, which the CNM's are not.
According to the CMS HCPC Code Set guidelines, modifier AS is to be billed a specific way:
1) Under the operating physicians NPI, not the assistants NPI
2) "The main surgeon should clearly specify in the medical record the medical necessity for utilizing the service of an assistant."

Our MD's are disputing that they need to document why an assistant was needed during the Cesarean Delivery. Even after showing them CMS guidelines on the documentation requirement, they state they have never had a denial or request before for not having a statement on why an assistant is medically necessary. They want me to bill the claim and just let them know if it denies for that, because they say it will not.
Does anyone have any information on if Cesarean Sections are specifically excluded from this requirement? Or am I misinterpreting CMS' guideline here. Could CMS be meaning that the Operative Report just has to have documentation that substantiates the need for an assistant, rather than an actual statement on exactly why they needed one?
Click to expand...
If you look at the Medicare data base (the one that includes the relative value units for all procedures), you will find a column on the excel file that indicates assistant at surgery (column U). The indicators are as follows:

0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
Note: Supporting documentation must be submitted at the time of claim submission to established medical necessity and should clearly document the assistant surgeon's role during the operative session.
1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.
2 = Payment restrictions for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.

For code 59510 the indicator is "1", for 59514 it is a "2" and for 59515 it is a "1"
For code 59618 the indicator is "0:, for 59620 it is a "2" and for 59622 it is a "0"

But these rules are not necessarily used by commercial payers. And if you notice, the rule for 59618 and 59622 makes no sense at all given the indicators assigned to 59510 and 59515. The American College of Surgeons publishes a list of procedures that require or do not require assistants at surgery and the latest edition for 2020 can be found at https://www.facs.org/-/media/files/...cians-as-assistants-at-surgery-consensus.ashx. If you examine their information, they have checked the column "almost always required" for all of the cesarean codes (59510-59515 and 59618-59622). This is a handy reference to rebut the need for additional documentation.
 
thomas7331 said:
I agree with the above, I have not seen payers enforce a requirement for specific documentation for an assistant or deny assistant claims due to specific medical necessity for an assistant not being documented in the procedure note. As a general rule, for procedures that routinely involve an assistant, it has been sufficient to simply document the name and credentials of the assistant in the record. But some physicians do include a description of what the assistant actually did during the procedure, and I think this is a good practice that could protect you in the event of an audit, and it's something that could be easily added into their template.

I'm a little puzzled in what you are saying about the CMS requiring the AS modifier to be billed by the operating physician - I think that guidance may be out of date. The assistant's service should be billed under their own NPI. Especially if the procedure is performed in a facility setting, it is inappropriate to bill any professional services as 'incident to' the physician's.
Click to expand...
I'm curious about the portion of this statement, the assistant's services being billed under the own NPI. Is that a requirement or just standard practice? In other words, can it be billed on the same claim as the main surgeon's same CPT, only the with the assistant's line item being listed with the AS modifier? I've been digging around the internet for a definitive answer. Any help is appreciated!
 
SarahCaldwell said:
I'm curious about the portion of this statement, the assistant's services being billed under the own NPI. Is that a requirement or just standard practice? In other words, can it be billed on the same claim as the main surgeon's same CPT, only the with the assistant's line item being listed with the AS modifier? I've been digging around the internet for a definitive answer. Any help is appreciated!
Click to expand...
It's a requirement that all providers bill their professional services under their own credentials - doing otherwise would be considered fraudulent. The only exception that is made is for those services that are performed 'incident to', which is the provision that allows providers who own their own practice to bill for the services of their employees when those employees are acting under the physician's supervision to carry out their plans of care. You can find the guidelines for what allows a service to be considered 'incident to' in the Medicare Benefit Policy Manual, but there are many articles on this topic that you can find here on AAPC or elsewhere on the internet.

One of the requirements for 'incident to' billing is that the services are performed in the provider's own office. Services performed in a facility would not be considered 'incident to' because the overhead costs associated with the services done there are the responsibility of the facility and not of the individual provider. So an assistant surgeon charge for a procedure done in a hospital would always have to be billed with the actual provider's credentials - the physician cannot claim that service as their own under 'incident to'. The two services could be on the same claim form if both the surgeon and assistant are employed by the same practice and use the same TIN, but the two providers would each be identified separately in box 24J.
 
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