Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: S-16-065
Topic: Assistant Surgery Eligibility Criteria
Section: Surgery
Effective Date: May 28, 2018
Issue Date: May 28, 2018
Last Reviewed: March 2018

An assistant at surgery is defined as a physician, nurse practitioner, clinical nurse specialist, or physician assistant who is licensed and actively assists the physician in charge of a case in performing a surgical procedure.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Procedures billed with the assistant at surgery physician modifiers -80, -81, -82 OR the AS modifier for physician assistants (PA), nurse practitioners (CRNP) and clinical nurse specialists (CNS), are subject to the Medicare Physician Fee Schedule Database (MPFSDB)*.

Payment may be made for the surgical procedures with these modifiers only if the services of an assistant surgeon are applicable.

The AS modifier must be reported on the claim form when billing physician assistant, nurse practitioners or clinical nurse specialists.

A Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) should not submit the "AS" modifier. This modifier is only valid for use by non-physician practitioners (NPP) when billing under their own provider number.   

Surgical assistance is not covered when performed by a doctor who performs and bills for another surgical procedure during the same operative session.

Payment will be made to a physician for assistant surgery performed by his/her employed physician assistant (PA), or certified registered nurse practitioner (CRNP) or certified nurse midwife (CNM).

*Assistant Surgery Payment Indicator

0

Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.

1

Statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery may not be paid.

2

Payment restriction for assistants at surgery does not apply to this procedure. Assistants at surgery may be paid.

9

Assistant at surgery concept does not apply.

 

Procedure Codes
See Table Attachment


Refer to medical policy S-112 Co-Surgery for additional information.

Refer to medical policy S-12 Team Surgery for additional information.

Refer to medical policy S-100 Multiple Surgical Procedures for additional information.

Refer to Highmark Reimbursement Policy Bulletin RP-001, Assistant at Surgery Services for additional information on reimbursement coverage.



Place of Service: Inpatient/Outpatient

Assistant at surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.