An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. (Note that a nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) who is authorized to provide such services under state law can also serve as an assistant at surgery). The conditions for coverage of such services in teaching hospitals are more restrictive than those in other settings because of the availability of residents who are qualified to perform this type of service.
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| Medical Policy: | N-28-015 |
| Topic: | Assistant at Surgery Services |
| Section: | CMS National Guidelines |
| Effective Date: | May 28, 2018 |
| Issue Date: | May 28, 2018 |
| Last Reviewed: | March 2018 |
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 PAs, NPs and CNSs, 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 for a PA, CNRP, or CNS.
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.
Physicians are prohibited from billing the member for assistant at surgery services for procedure codes subject to the assistant at surgery limit.
Payment may not be made to assistants at surgery for surgical procedures in which a physician is used as an assistant at surgery in fewer than five (5) percent of the cases for that procedure nationally.
*Assistant Surgeon Payment Indicators
|
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. |
Diagnosis Codes Section
N/A
Refer to Medicare Advantage medical policy N-113 Nurse Practitioner Services for additional information.
Refer to Medicare Advantage medical policy N-115 Clinical Nurse Specialist Services for additional information.
Refer to Medicare Advantage medical policy N-116 Services of Physician's Assistants for additional information.
Refer to Highmark Reimbursement Policy Bulletin RP-001, Assistant at Surgery Services for additional information on reimbursement coverage.
| The policy position applies to all Medicare Advantage lines of business |
| Denial Statements |
Services denied as not reasonable and medically necessary, under section 1862(a)(1) of the Social Security Act, are subject to the Limitation of Liability provision. A contracted provider must inform the enrollee to request an organization determination from the plan or the provider can request the organization determination on the enrollee’s behalf. Failure to provide a compliant denial to the enrollee means that the enrollee is not liable for services provided by a contracted provider or upon referral from a contracted provider.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
3/2018, Policy Coverage Update Assistant at Surgery Services
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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.
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