This policy applies to professional providers billing professional or outpatient facility claims, for members enrolled in all Company products.
Modifiers 80, 81, 82, and AS indicate instances when it is medically necessary for a primary surgeon to require the services of a surgical assistant during a procedure. 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-at-surgery 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.
When assistant-at-surgery services meet all reimbursement eligibility requirements in this policy, such services are reimbursed at 16 percent of the surgical allowance.
In a teaching hospital, with a Graduate Medical Education (GME) program, assistant-at-surgery services performed by a physician or non-physician healthcare practitioner (i.e. PA, or NP/CRNP, or CNS) are not eligible for reimbursement consideration by the Company except for the following circumstances;
- When exceptional medical circumstances (e.g. emergency, life-threatening situations such as multiple traumatic injuries) require immediate treatment.
- A surgeon does not participate in the teaching facility's GME program and/or the primary surgeon has a policy never to involve residents in the preoperative, operative or postoperative care of patients.
Interns, residents, or fellows in GME programs are not recognized as eligible professional providers and, therefore, the Company does not consider assistant-at-surgery services provided by interns, residents, or fellows in GME programs as eligible for reimbursement consideration, regardless of the procedure code indicator.
- Multiple procedures reported as assistant-at-surgery services are subject to multiple surgery reduction guidelines.
- The postoperative period corresponding to the procedure code is not applied to assistant-at-surgery services.
- Only one physician or non-physician healthcare practitioner performing assistant-at-surgery services is eligible for reimbursement consideration.
- For assistant-at-surgery services to be eligible for reimbursement consideration, the service must be a covered benefit. Individual member benefits must be verified.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Claims submitted with modifier 80, 81, 82, and AS are subject to pre- and post-payment review and potential denials or retractions for inappropriate use.
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 must be reported.
- Assistant-at-surgery services provided by a physician or non-physician healthcare practitioner (i.e. PA, or NP/CRNP, or CNS) must be reported with the same procedure code(s) as reported by the primary surgeon.
- Each procedure code representing an assistant-at-surgery service performed by a non-physician healthcare practitioner must be appended with an assistant-surgery modifier (80, 81, 82) in the first modifier position and modifier AS (non-physician health care practitioner) in the second modifier position.
- Assistant-at-surgery services should not be reported for 'global' procedures (e.g. maternity care). Assistant-at-surgery services may be reported for 'non-global' surgical procedures (e.g. delivery only) when appropriate.
- Assistant-at-surgery services performed by a nonphysician health care practitioner must meet all local, state, and national licensing, certification, and supervision requirements. (removed from previous sub-bullet to its own stand alone bullet)
- The assistant-at-surgery may not report any other service, surgical or otherwise (e.g., co-surgery), during the same operative session.