Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS

Policy #:00.10.18j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

When assistant-at-surgery services meet all reimbursement eligibility requirements in this policy, such services are reimbursed at 16 percent of the surgical allowance.

The Company applies the following Medicare Physician Fee Schedule database assistant-at-surgery indicators to procedure codes to determine the eligibility for reimbursement consideration for assistant-at-surgery services:

0 =
Procedure codes that carry a 0 indicator are subject to medical necessity documentation review for reimbursement consideration for assistant-at-surgery services.
  • Upon receipt and processing of claims submitted, the Company will communicate any additional supporting medical necessity documentation requirements. However, providers should not submit medical records to the Company until notified.
1 =
Procedure codes that carry a 1 indicator are not eligible for reimbursement consideration for assistant surgeon services. The Centers for Medicare & Medicaid Services (CMS) has determined that these services never warrant an assistant-at-surgery.
  • All claims received for reimbursement for assistant-at-surgery services represented by procedure codes with a 1 indicator will be denied by the Company.
2 =
Procedure codes that carry a 2 indicator are eligible for reimbursement consideration for assistant-at-surgery services.

9 =

The concept of assistant-at-surgery does not apply to procedure codes that carry a 9 indicator.
  • All claims received for assistant-at-surgery services that are represented by procedure codes that carry a 9 indicator, and for which the concept of assistant-at-surgery does not apply, and considered invalid procedure code/modifier combination.

BILLING REQUIREMENTS

The Company has established the following requirements for the appropriate reporting of Modifiers 80, 81, 82, and AS:
  • The assistant surgeon modifier (80, 81, 82, or AS) that accurately represents the circumstance in which the surgery was performed should be reported.
  • Assistant-at-surgery services provided by a physician must be reported with the same procedure codes as reported by the primary surgeon. An exception to this is when the primary surgeon bills a global code (e.g., maternity care). In that case, the assistant-at-surgery must bill the specific surgery-only code (e.g., delivery only) appended with Modifier 80, 81, or 82.
    • When multiple procedures are performed as surgical assistance, each procedure code representing an assistant-at-surgery service must be appended with an assistant surgeon modifier (i.e., 80, 81, 82).
  • Assistant-at-surgery services provided by a nonphysician health care practitioner (i.e., PA, NP/CRNP, or CNS) must be reported with the same codes as the primary surgeon. An exception to this is when the primary surgeon bills a global code (e.g., maternity care). In that case, the nonphysician health care practitioner must bill the specific surgery-only code (e.g., delivery only).
    • Assistant-at-surgery services performed by a nonphysician health care practitioner must meet all local, state, and national licensing, certification, and supervision requirements.
    • When multiple procedures are performed as surgical assistance, each procedure code representing an assistant-at-surgery service must be appended with an assistant-surgery modifier (80, 81, 82) in the first modifier position and Modifier AS (nonphysician health care practitioner) in the second modifier position.
  • Modifer 81 should be used when more then one assistant surgeon is required during the same operative session.
  • The assistant-at-surgery may not report any other service, surgical or otherwise (e.g., cosurgery), during the same operative session.

ADDITIONAL INFORMATION
  • Multiple procedures reported by an assistant-at-surgery are subject to multiple surgery reduction guidelines.
  • The postoperative period corresponding to the procedure code is not applied to assistant-at-surgery services.
  • Interns, residents, or fellows in graduate medical education (GME) programs are not recognized as eligible professional providers and, therefore, the Company does not consider assistant-at-surgery services provided by these professional providers as eligible for reimbursement consideration, regardless of the procedure code indicator.
  • The need for an assistant at surgery must be documented in the medical record with a clear indication of the active surgical participation as the assistant at surgery.
  • For assistant-at-surgery services to be eligible for reimbursement consideration, the service must be a covered benefit. Individual member benefits must be verified.

Guidelines

This policy is consistent with Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.


BILLING GUIDELINES

In order to receive the appropriate reimbursement, surgical procedures performed by both a primary surgeon and an assistant-at-surgery should be reported as follows:
  • For surgical procedures performed on the same date of service, the primary surgeon should submit a claim form with the surgical procedure code(s) for the services performed, and the assistant-at-surgery should submit a separate claim form with the same surgical procedure code(s) reported by the primary surgeon appended with the appropriate modifier.
  • For surgical procedures performed on different dates of service, the primary surgeon should submit a separate claim form for each date of service with the surgical procedure code(s) for the services performed. The assistant-at-surgery should submit a separate claim form from the primary surgeon for each date of service with the same surgical procedure codes(s) reported by the primary surgeon appended with the appropriate modifier.

Inappropriate billing may result in claim overpayments and subsequent retractions or claim underpayments.

Description

The following modifiers are appended to certain procedure codes when a surgical procedure requires both a primary surgeon and an assistant-at-surgery due to its complexity and/or duration. The assistant-at-surgery actively supports a primary surgeon during a surgical procedure:

  • Modifier 80: Assistant Surgeon
  • Modifier 81: Minimum Assistant Surgeon
  • Modifier 82: Assistant Surgeon [when qualified resident surgeon not available]
  • Modifier AS: Physician Assistant (PA), Nurse Practitioner (NP/CRNP) or Clinical Nurse Specialist (CNS) services for Assistant-at-surgery

As used in this policy, the term assistant-at-surgery may refer to either a physician (i.e., medical doctor [MD], doctor of osteopathy [DO]), or a nonphysician health care practitioner (i.e., PA, NP/CRNP, or CNS) who provides assistant-at-surgery services.
References

Optum360. 2018 Understanding Modifiers: Softbound.


American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. §40.8. pg. 95-97. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Centers for Medicare & Medicare Services (CMS). PFS Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the ASST SURG column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)





Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)




HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the ASST SURG column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)



Revenue Code Number(s)

N/A


Misc Code

Modifiers:

80: Assistant surgeon
81: Minimum assistant surgeon
82: Assistant surgeon (when a qualified resident surgeon not available)
AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant-at-surgery


Coding and Billing Requirements


Cross References


Policy History

REVISIONS FROM 00.10.18j:
01/01/2018Revised policy number 00.10.18j was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.
Version Effective Date: 01/01/2018
Version Issued Date: 01/05/2018
Version Reissued Date: N/A

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