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30.2.35.3 Assistant Surgeons
An assistant surgeon assists the primary surgeon during a complex surgical procedure that warrants an assistant to safely and effectively accomplish the procedure.
Assistant surgeons may be reimbursed 16 percent of the prevailing fee for the surgical procedure performed.
The CSHCN Services Program follows the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 regulation for assistant surgeons in teaching hospitals.
An assistant surgeon is not paid in a hospital classified by Medicare as a teaching facility with an approved graduate training program in the performing physician's specialty. These claims are paid only if modifiers 82 or 80 (assistant surgeon) and KX (documentation on file) are present on the claim. These modifiers should be used in the following situations:
• There are exceptional medical circumstances, such as emergency or life-threatening situations that require immediate attention.
•The primary surgeon has a policy of never, without exception, involving a resident in the preoperative, operative, or postoperative care of their clients.
•The surgical procedure is complex and qualifies for more than one physician.
•Use modifier 82 when no qualified resident was available to assist with the surgery.
If the physician seeks an exception to the TEFRA regulation based on unavailability of a qualified resident, the following certification statement must appear on or be attached to the claim form:
"I understand that Section 1842(b)(6)(D) of the Social Security Act generally prohibits reasonable charge payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services for which payment is claimed were medically necessary, and that no qualified residents were available to perform the services. I further understand that these services are subject to postpayment review by TMHP-CSHCN."
Payment to an assistant surgeon for multiple surgical procedures follows the same guidelines as payment to the primary surgeon.
If an assistant surgeon bills separate charges for local or regional anesthesia and assistant surgery on the same day, the anesthesia is included as part of the surgical procedure and not reimbursed separately.
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