Coding Corner: Medicare rules for teaching hospitals | David Holtz, MD

David Holtz, MD

“I have a PA assist me at the bedside during my robotic cases, and a resident wants to come in to learn on the console. The hospital pays the PA – what can we do so the hospital can still bill for the PA?”

Medicare has specific rules for teaching hospitals regarding surgical assistance. The Centers for Medicare & Medicaid Services (CMS) provides teaching hospitals with money to compensate for resident salary and time and they want to avoid paying for an assistant on top of those budgeted amounts. Medicare is also required by statute to pay for care that is “reasonable and necessary”. The Medicare Physician Fee Schedule Database (MPFSD) lists if assistant at surgery services are allowed for a given CPT code. The MPFSD can be accessed online.

Private insurers generally follow Medicare rules, but not uniformly, so you should check with the plans individually on an annual basis.

It is not enough to simply state that an assistant was at surgery in your operative note.  To bill for an assistant, the surgeon has to indicate what role the assistant at surgery performed: prepping the patient, manipulating the uterus, swapping instruments, etc.  If you are at a teaching institution you must also indicate why a resident was not available.  They could be unavailable due to educational responsibilities, or a resident of the appropriate skill level might not be available.  The residents at my institution do not go through a bedside assistant training program, and I indicate in my operative note specifically that no resident trained as a bedside assistant was available.

Proper modifiers then must be submitted with the CPT codes to indicate that a call assistant was required and that no qualified resident was available. 

Modifier 82 indicates that the procedure was performed requiring the presence of an assistant surgeon when a qualified resident surgeon was not available. In teaching hospitals, special requirements must be met to allow billing for an assistant surgeon, and modifier 82 is typically used in those instances. Check with your Medicare carrier for details.

Modifier AS-Assistant at Surgery- should also be used to indicate a physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery.

Documentation required in the medical record:

1. A statement that no qualified resident was available to perform the service, or
2. A statement indicating that exceptional medical circumstances exist, or
3. A statement indicating the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

Let us assume that you are doing a relatively common procedure in the world of gynecologic oncology: a robotic hysterectomy, bilateral salpingo-oophorectomy, and sentinel lymph node biopsy for endometrial cancer. The procedure codes (58571 for TLH/BSO, 38570 for laparoscopic lymph node sampling, 38900 for dye injection) all allow for an assistant at surgery. The procedure code modifier as -82 and-AS would be appended to each of these CPT codes.  A notation of why a qualified resident was not available, as well as an indication of what the surgical assistant performed, should be placed in the surgical operative note. Be prepared to send documentation to the insurance company.

A thorough discussion of these rules can be found at the CMS website.

David Holtz, MD, is a gynecologic oncologist at Lankenau Hospital in Wynnewood, PA.