An “assistant at surgery” refers to a licensed professional who actively assists the operating surgeon while performing a surgical procedure. This assistant surgeon provides more than just ancillary services. “Assistant at surgery” is a billable service and Medicare allows 16% of the usual surgical allowance for this service. Successful billing relies on how physicians document operative reports and use modifiers. Medical billing and coding outsourcing helps busy surgeons to deal with claim documentation and submission.

Medicare does not reimburse Registered Nurse First Assistants (RNFAs) for assistant-at-surgery but reimburses Advanced Registered Nurse Practitioners (ARNP), Clinical Nurse Specialists (CNS), and Physician Assistants (PA) if the service is within their state scope of practice, protocol, and hospital granted privileges.

An assistant surgeon is considered medically necessary when the complexity of the operation necessitates the primary surgeon to have additional skilled operative assistance from – another surgeon, a licensed physician assistant or a registered nurse first assistant.

Payment Policy Indicators and Documentation Requirements

Medicare’s payment policy indicator determines whether an assistant-at-surgery will be reimbursed or not. These indicators are as follows:

  • 0 = Medicare may pay for an assistant-at-surgery if the medical record documentation supports the medical necessity for the assistant. Here, providers should document patient and procedure characteristics which necessitate the services of an assistant surgeon.
  • 1 = Assistant-at-surgery may not be paid, as statutory payment restriction applies to this procedure. For this indicator designated procedures, along with documenting why an assistant is required for the surgery, if the chart notes are requested for review that information should be documented.
  • Physicians should note that patient cannot be charged for this service. It is recommended not to ask the patient to sign an Advanced Beneficiary Notice (ABN) to shift financial responsibility from the provider to the patient. Even if you receive a denial, it is highly unlikely that the denial will be overturned on appeal, regardless of the level of appeal.
  • 2 = As payment restrictions for the service does not apply to this procedure, assistant-at-surgery may be paid for this procedure.

To get these services supported, surgeons must remember to include what the assistant surgeon contributed to the surgery in the body of the operative note.

In a teaching setting, Medicare will only pay for assistant-at-surgery when the procedure is done by a physician who is primarily engaged in the field of surgery, and the primary surgeon does not use interns or residents; there is no resident training program relating to the specialty required for the surgery; a resident in a training program relating to the specialty required for the surgery is unavailable, or the service is required as a result of an exceptional medical circumstance.

Using Modifiers

Appropriate use of modifiers is necessary when reporting these services. Certain modifiers are submitted with the surgical procedure code for which the assistant-at-surgery was involved. Claims for services of an assistant surgeon should be filed with modifier 80, 81, 82 or AS.

  • 80 Modifier – This modifier is used when the assistant at surgery service was provided by a medical doctor (MD).
  • 81 Modifier – This modifier helps to identify minimum surgical assistant services, and must be submitted only with surgery codes. In case, if the operating physician plans to perform a surgical procedure alone and only requires the service of an assistant surgeon for a short period of time, this is considered a minimum assistant surgeon.
  • 82 Modifier – Use this modifier when the assistant at surgery service was provided by an MD and there was no qualified resident available. Documentation must include information stating that a qualified resident was not available during the procedure.
  • AS Modifier – Use the modifier “AS” for assistant at surgery services provided by a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS). Medicare further reduces the assistant-at-surgery allowance by 15% when provided by an ARNP, CNS, or PA.

Operative notes should highlight assistant surgeon’s role

The body of the operative note needs to include what the assistant surgeon contributed to the surgery and their role in the session. Also ensure that the name and credentials of the assistant surgeon are documented. To support modifier 82, the operative note should also state why there was no qualified resident available and why a non-resident assistant had to assist with the surgery.

With accurate and complete medical documentation, an experienced medical billing service provider can help providers submit accurate and timely claims for the procedures performed.