Payment of assistant surgery services may be made if all the following
conditions are met:

1. The operation is a covered surgical procedure.
   
   
2. The operation is of sufficient difficulty and complexity to require an assistant surgeon:
   
   
   • Procedure codes on the Procedure Code Attachment are eligible for assistant surgery payment.
   • Payment for not otherwise classified procedures requires medical review.
   • Any other procedures are not routinely eligible for assistant surgery payment.
     
     
3. The assistant surgeon must actively assist in the surgery:
   
   
   • To "actively assist" means that the assistant surgeon must assist in the actual performance of the surgical procedure. Also, the assistant surgeon, in the event the surgeon is unable to continue, should be able to complete the surgery.
   • 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). Both modifiers 80 and AS must be used to report assistant surgery performed by an employed PA or CRNP.

Payment will also be made for assistant surgery performed by an independently practicing CRNP.  Independently practicing CRNPs should report assistant surgery with modifier 80.

Assistant surgery denied on the basis of codes on the Procedure Code Attachment below is considered a medical necessity denial. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Assistant surgery during cataract surgery (codes 66820, 66821, 66830, 66982, 66983, 66984, and 66985) is not eligible unless documentation supports the medical necessity of the service. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

NOTE:

Also see Medical Policy Bulletin S-112 (Co-Surgery).

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.

FEP covers assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures or delivery.