Assistant at Surgery

Reimbursement Policy:

Assistant at Surgery

Effective Date:

February 1, 2008

Revision Date:

November 30, 2015

Purpose:

Provide guidelines for the reimbursement and eligibility of Assistant at Surgery modifiers. This policy applies to professional providers.

Scope:

All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

• Assistant at Surgery: Practitioner who actively assists the physician in charge in performing surgical procedures.
• Modifier 80: Used when the assistant surgeon services were provided by a medical doctor.
• Modifier 81: Used to identify minimum assistant surgeon services; only submitted with surgery codes.
• Modifier 82: used when the assistant surgeon services were provided by a medical doctor and no qualified resident was available.
• Modifier AS: Used when the assistant surgeon services were provided by a Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS), Registered Nurse First Assistant (RFNA)

Policy:

In accordance with Assistant Surgeon College (ASC) guidelines, Horizon BCBSNJ considers an assistant at surgery medically necessary when the complexity of the surgical procedure necessitates the primary surgeon have additional skilled operative assistance from any of the following:

1. Another surgeon
2. A licensed Physician Assistant/Nurse Practitioner
3. A Registered Nurse First Assistant

For a list of procedure codes in which an assistant at surgery is NOT considered medically necessary, please review Horizon BCBSNJ Medical Policy Assistants at Surgery.

Procedure:

In accordance with The Center for Medicare and Medicaid Services (CMS), when Assistant at Surgery modifiers are appropriately appended, Horizon BCBSNJ shall reimburse as follows:

Multiple procedure reductions shall apply if an assistant at surgery submits multiple procedure codes. For additional information on multiple procedure reductions, please refer to Horizon BCBSNJ’s reimbursement policy Multiple Procedure Reductions.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Policy 091_v1.0_10122015