Description
When a surgical assistant supports a surgeon in performing a procedure, Medicare considers this procedure to have an assistant at surgery. The Medicare Physician Fee Schedule (MPFS) allows physicians’ surgical services to be billed as assistant at surgeries, provided that the procedure code has an assistant at surgery indicator of “0” or “2” and that the use of an assistant at surgery was medically necessary. When billing for assistant at surgery services, the provider must append the appropriate assistant at surgery modifier to the respective procedure code. By appending an assistant at surgery modifier to the procedure code on the claim, the provider receives a reduced payment of the established MPFS amount for the billed surgical service. Documentation will be reviewed to determine if an assistant surgery modifier was missing from the claim.
Affected Code(s)
CPT code range 10021 through 69990 with assistant at surgery indicator of “0” or “2”
Applicable Policy References
1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(a)(1)(O)- Payment of Benefits
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
4. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review
5. 42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request
6. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening
8. 42 Code of Federal Regulations (CFR) §414.4- Payment for Part B Medical and Other Medical Services
9. 42 Code of Federal Regulations (CFR) §414.40- Coding and Ancillary Policies
10. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Basic conditions- Sufficient information
11. 42 Code of Federal Regulations (CFR) §424.32- Basic requirements for all claims
12. 45 Code of Federal Regulation (CFR) §162.1002(a)(5)- Medical data code sets
13. Medicare Benefit Policy Manual Chapter 15 §200 - Nurse Practitioner (NP) Services
14. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.3
15. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §40.8- Claims for Co-Surgeons and Team Surgeons
16. Medicare Claims Processing Manual Chapter 12 – Physician Practitioner Billing, § 100.1.7.B.
17. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants
18. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §120 - Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services
19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
20. American Medical Association. “Modifiers Used with Surgical Procedures”, CPT Assistant, Fall 1992, page 15.
21. American Medical Association. "A Closer Look at the Use of Surgical Modifiers" CPT Assistant, March 1996: 8.
22. AMA CPT Codebook
23. Medicare Physician Fee Schedule (MPFS) Physician Fee Schedule | CMS