Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and policy criteria listed below.
The American College of Surgeons (ACS) has determined that assistant surgeon services are required for the successful completion of certain surgical procedures that have been identified as sufficiently complex or intensive.
Providers rendering assistance at surgery (“Assistant Surgeon services”) should report such services by appending the modifier 80, 81, 82, or AS, as appropriate, to a specific Current Procedural Terminology (CPT®1) code. Each modifier identifies a unique situation.
• 80 ‐ Physician providing assistance in surgery
• 81 ‐ Physician providing minimum assistance in surgery
• 82 ‐ Physician providing assistance in surgery when qualified resident not available
• AS – Non‐physician providing assistance in surgery (such as an RNFA or PA)
The Health Plan considers the following points to be important considerations in the adjudication of an Assistant Surgeon claim:
1. The provider of service must be a licensed practicing M.D., D.P.M., D.D.S., D.O., Physician Assistant (PA), RNFA (Registered Nurse First Assistant) or CNM (Certified Nurse Midwives) to be eligible for reimbursement as an Assistant Surgeon for a covered procedure.
2. Only one Assistant Surgeon is eligible for reimbursement per covered surgical procedure.
3. CPT codes reported with an Assistant Surgeon modifier are subject to multiple surgery reimbursement rules, if applicable. Assistant Surgeon services are eligible for reimbursement as follows:
• Assistant Surgeon services reported with modifiers 80, 81, and 82 will be eligible for reimbursement at 16% of the allowed amount for the primary procedure. Multiple surgery reimbursement rules are applied to subsequent procedures, if applicable.
• Assistant Surgeon services reported with modifier AS will be eligible for reimbursement at 16% of the allowed amount under the applicable physician extender fee schedule. If there is no applicable physician extender fee schedule, the Assistant Surgeon services will be eligible for reimbursement at 10% of the allowed amount for the primary procedure. Multiple surgery reimbursement rules are applied to subsequent procedures, if applicable.
4. Procedures reported with an unlisted CPT code will be retrospectively reviewed for pricing and eligibility for reimbursement for an Assistant Surgeon.
5. Assistant Surgeon claim editing is administered uses edit designations that are tailored to physicians. However, the Health Plan applies the same edit designations to non‐physician assistants.
6. Some procedures may require assistance for positioning, and retraction for maintaining visualization. However, this type of assistance can usually be performed by a surgical technician and does not require Assistant Surgeon services.
Claims for Assistant-at-Surgery Services
For assistant-at-surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.
MACs may not pay assistants-at-surgery for surgical procedures in which a physician is used as an assistantat-surgery in fewer than five percent of the cases for that procedure nationally. This is determined through manual reviews.
Procedures billed with the assistant-at-surgery physician modifiers “-80” (Assistant Surgeon), “-81” (Minimum assistant surgeon), “-82” (Assistant surgeon (when qualified resident surgeon not available)), or the AS modifier (physician assistants, nurse practitioners and clinical nurse specialists), are subject to the assistant-atsurgery policy. Accordingly, Medicare pays claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized.
Medicare’s policies on billing patients in excess of the Medicare allowed amount apply to assistant-at-surgery services. Physicians who knowingly and willfully violate this prohibition and bill a beneficiary for an assistant-atsurgery service for these procedures may be subject to the penalties contained under §1842(j)(2) of the Social Security Act (the Act). Penalties vary based on the frequency and seriousness of the violation.
Method II Critical Access Hospitals (CAHs) assistant-at-surgery services rendered by a physician or nonphysician practitioner that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, or 98X and an appropriate assistant-at-surgery modifier.