Surgery Modifiers Require Specific Documentation

Surgery Modifiers Require Specific DocumentationOver my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra set of hands to execute the surgery. That used to be enough for payers, but not anymore.

Payers Want More Info

Payers no longer consider the assistant surgeon’s name in the header only as sufficient documentation. They want the body of the operative note to indicate what the assistant surgeon contributed to the surgery. They also want documentation in the operative report to explain why an assistant surgeon was used at a teaching institution rather than a qualified resident.

An Assistant at Surgery modifiers Fact Sheet published by Novitas Solutions, Part B Medicare Administrative Contractor for Jurisdiction JL (District of Columbia, Delaware, Maryland, New Jersey, and Pennsylvania), provides instructions for claims and documentation when an assistant surgeon is utilized.

Support Modifier 82

Of interest in the fact sheet is the information related to the use of surgery modifiers 82 Assistant surgeon – when qualified resident surgeon not available. The fact sheet states, “Documentation must include information relating to the unavailability of a qualified resident in this situation.”

This means you cannot assume there wasn’t a qualified resident available. To support surgery modifiers 82, the operative note should state:

  • why there was no qualified resident available; and
  • why a non-resident assistant had to assist with the surgery.

When coding or auditing surgeries performed at a teaching facility, make sure this information is included in the body of the operative note.

State The Assistant’s Purpose

A note in the fact sheet states:

“The operative note should clearly document the assistant surgeon’s role during the operative session.”

This means that the mention of an assistant surgeon only in the operative note header is not enough to support coding for and billing for an assistant surgeon’s services. The operative not needs to include what the assistant surgeon contributed to the surgery in the body of the operative note.

Robotic surgeries usually indicate that the assistant surgeon provided the patient side support for the robotic system while the primary surgeon operated the robotic system, usually at a distance from the patient. Operative notes for non-robotic surgeries are less likely to mention what the extra pair of hands did in the surgery. Remind surgeons that they must include what the assistant surgeon contributed to the surgery in the body of the operative note so that their services are supported.

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