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, physician assistant or clinical nurse specialist 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.

For assistant at surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the global surgery.

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 percent of the cases for that procedure nationally. This is determined through manual reviews.

In addition to the assistant at surgery modifiers “-80,” “-81,” or “-82,” any procedures submitted with modifier AS are subject to the assistant surgeon’s policy enunciated in the Medicare physician fee schedule database (MPFSDB). Accordingly, payment may be made for the surgical procedures with these modifiers only if the services of an assistant surgeon are authorized.

Physicians are prohibited from billing the member for assistant at surgery services for procedure codes subject to the assistant at surgery limit. Physicians who knowingly and willfully violate this prohibition and bill a member for an assistant at surgery service for these procedures codes may be subject to the penalties contained under §1842(j)(2) of the Social Security Act (the Act.) Penalties vary based on the frequency and seriousness of the violation.

See Medicare Advantage Medical Policy Bulletin N-113 for additional information on assistant surgery performed by a nurse practitioner.

See Medicare Advantage Medical Policy Bulletin N-115 for additional information on assistant surgery performed by a clinical nurse specialist.

See Medicare Advantage Medical Policy Bulletin N-116 for additional information on assistant surgery performed by a physician assistant.

NOTE:

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.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual Pub. 100-04, Chapter 12, Section 20.4.3, 100.7B, 110.3A

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