October 19, 2017
We are seeing payers ask for payment back when we use Modifier 80 for assistant surgeon. Is there a reason why they would take the payment back?
Without additional information it is difficult to respond to your inquiry. First, Medicare has a list of surgical CPT codes where payment will be considered for an assistant surgeon. Some codes will be paid without documentation submitted, some codes will be considered for payment if documentation of medical necessity is present and other codes will not be considered for payment at all (e.g. when less than 5% of the codes have an assistant surgeon reported). It is helpful to review this as a first step to understanding the denial. If the code allows an assistant and the service is still denied, documentation needs to be reviewed. An assistant surgeon does not create a separate operative note for his/her role as an assistant. The primary surgeon is responsible for documenting the name and credentials of the assistant surgeon, and the work performed and medical necessity of the assistant must be documented in every operative note when services for the assistant are reported. Payors are no longer always paying claims when the assistant’s name is the only information reported.
*This response is based on the best information available as of 10/19/17.