Assistant at Surgery

Policy ID: NDRP-SURG-001

Section: Surgery

Effective Date: July 01, 2018

Revision Effective Date: October 23, 2023

Last Reviewed: August 12, 2024

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement for services provided by an Assistant Surgeon.

Description

Assistant Surgeon

Minimum Assistant Surgeon

Assistant Surgeon (when qualified resident surgeon not available)

Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS) services for Assistant at Surgery

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Policy

An assistant surgeon actively assists the primary surgeon performing a surgical procedure. Assistant surgeons submit procedure code(s), with the appropriate modifier appended (80, 81, 82, or AS) to represent their service(s). The reimbursement amount is dependent upon the assistant surgeon modifier appended to the surgical code submitted. Only one assistant surgeon will be reimbursed for each eligible procedure.

Reimbursement Percentage

20% of the fee schedule

17% of the fee schedule (Fee Schedule Amount x 85%) x 20%

Note: Multiple procedure reductions may apply if an assistant at surgery submits multiple procedure codes. Refer to the Multiple Procedures Payment Reduction for Medical and Surgical Services Reimbursement Policy for additional information.

Assistant at Surgery Eligible Codes

The assistant at surgery procedure code eligible list is developed based on The Center for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) Relative Value Unit (RVU) File status indicators. All codes in the CMS PFS RVU File with the status indicator "0" or “2” for “Assistant at Surgery” are reimbursable for assistant at surgery services, when indicated by an assistant surgeon modifier (80, 81, 82, or AS). (Status indicator “0” will be reimbursable effective January 1, 2024.)

Note: BCBSND updates codes quarterly when made available by CMS and the American Medical Association (AMA).

Limitations & 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, payment integrity edits and medical necessity
Mandated or legislative required criteria will always supersede.

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

Cross References

History

Date

Updates

6/26/2020

Updated policy section for how assistant surgery claims are submitted. The identical code as the primary surgeon is not required in all situations.

4/25/2021

Added a note that codes are updated quarterly.

9/28/2021

Updated cross references and policy format.

5/6/2022

Removed CMS Assistant at Surgery status indicator table.

7/18/2022

Policy reviewed.

7/10/2023

Annual policy review completed.

10/23/2023

Added status indicator “0” will be reimbursable effective January 1, 2024.

8/12/2024

Policy annual review completed and legal disclaimer added.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

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