You are absolutely correct. The primary surgeon (surgeon of record) dictates the operative note. He or she should dictate the role, medical necessity, and work performed by an assistant (if one is involved in the surgery). If an assistant surgeon (MD or DO) or an assistant at surgery (PA, NP, or CNS) is used, the primary surgeon is responsible for justifying the presence of the assistant, the medical necessity requiring the assistant’s presence, and the work performed.
An assistant, who is billing for his or her services, does not dictate an operative note. If the primary surgeon does not include the information in the operative note, there is no basis to report the assistant’s service. If the bill is denied, the assistant has no documentation to support an appeal.
Donna