Wiki Modifier 80 and Modifier AS

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maddismom

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We have the following situation:

Provider outside of our practice performed surgery
Physician in our practice assisted
PA in our practice also assisted.

We billed surgical code with Mod 80 for the physician and surgical code with Mod AS for the PA.

The insurance only wants to pay for the physician with the Mod 80. I am unable to locate anything that states we cannot bill for BOTH the physician and the PA as assists.

Does anyone have any information or references regarding this situation? I have not encountered this before.

Thank you!
 
maddismom said:
We have the following situation:

Provider outside of our practice performed surgery
Physician in our practice assisted
PA in our practice also assisted.

We billed surgical code with Mod 80 for the physician and surgical code with Mod AS for the PA.

The insurance only wants to pay for the physician with the Mod 80. I am unable to locate anything that states we cannot bill for BOTH the physician and the PA as assists.

Does anyone have any information or references regarding this situation? I have not encountered this before.

Thank you!
Click to expand...

Here is one payer's policy stating that they only allow 1 surgical assistant per procedure; this is pretty much in line with others that I've seen. We are often in the same situation, having both an MD and PA assist for other physicians, yet are only able to bill for the MD.
Hope this helps!

https://www.oxhp.com/secure/policy/assistants_at_surgery_711.html
 
I can certainly understand why the insurance company does not want to pay for a PA and a surgeon to both assist. Usually a surgery doesnt need more than a surgeon and an assistant so there would be no reason for them to pay for the PA and the surgeon. 2 qualified surgeons should be enought to do a surgery, should not need a PA to assist also.
 
As I did not go to medical school, I don't feel I'm qualified to make the judgement on how many physicians or assistants it would take to perform or assist on a surgery. If you have direct knowledge of the surgery (which I did not name) or something concrete other than the above opinion, please share this nformation.
 
There is really no reason to get offended or post a response such as what you did. What I posted was not an opinion. What I posted was billing advice given by attending 15 years of AANS and NASS seminars. Unless it is a very unusual surgery or situation we have been told not to bill for both the PA and a surgeon to routinely assist at surgeries. I will make sure not to answer any posts of yours in the future, I did not intend to offend you, simply to answer your question.
 
Payer rules vary as to how many assistants (if any) they will allow for specific surgical procedures.

In making an appeal, you'd need to support medical necessity by virtue of the provider's note which should clearly document why two surgical assists were required outside the typical surgical case. Common reasons might be body habitus (morbid obesity), unusual anatomy, or significant extra work due to an unusual condition or situation, excluding surgeon error.

I also wanted to comment in regards to your post to penguins11; maybe you didn't intend for it to seem so unfriendly. If you don't want to read the responses, perhaps you might not want to post questions. After all, this is a professional discussion board, with very little content monitoring. You can choose to disregard any post you choose, but we all have the right to post our opinions. Hope you understand.
 
Of course I didn't mean to sound unfriendly. And I'm sure penguins11 did not mean to sound patronizing, either. The second response was much more helpful with "Unless it is a very unusual surgery or situation we have been told not to bill for both the PA and a surgeon to routinely assist at surgeries." That type of information is what I was looking for.
 
A follow up question to your question. As of the first of the year we are getting denied on all "AS" physician assisant billing from Noridian Medicare. Is anyone else having this issue? Thank you!
 
Last edited:
lostone65 said:
Thank you so much Meagan! I scoured the forum and never found that thread for some reason. We do several PA assists a week in our practice and this info will save the day!
Thanks again!
Click to expand...

No problem, happy to help!! All of our surgeons use PA's; I'm just waiting for Pinnacle to jump on board with this like others have so far and complicate things that much more! :p
 
lostone65 said:
A follow up question to your question. As of the first of the year we are getting denied on all "AS" physician assisant billing from Noridian Medicare. Is anyone else having this issue? Thank you!
Click to expand...

Yes...we just heard this for the very first time today! We are questioning how this is applied/interpreted. The only other information we can locate has to do with Method II CAH's and PA's reassigning their billing rights to the hospital. Our hospital is not a CAH, nor have the PA's reassigned their billing rights. This has caused a lot of conversation and attempted research to say the least! If anyone has more information, please share! :eek:
 
Just an update that two of the surgeries where both a PA and a surgeon assisted and were coded were paid by the insurance. Just a reminder that you can't believe everything people tell you here and sometimes you need to just keeping fighting to get your physicians paid!
 
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