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36.4.47.3 Assistant Surgeon
Assistant surgeons are reimbursed 16 percent of the TMRM fee for the surgical procedures performed.
Medicaid follows the TEFRA regulations for assistant surgeons in teaching hospitals. TEFRA states that an assistant surgeon will not be paid in a hospital classified by Medicare as a teaching facility with an approved graduate training program in the performing physician's specialty. One of the following situations must be present and documented on the claim:
• No qualified resident was available (modifier 82 may be used to document this exception).
•There were exceptional medical circumstances such as an emergency or life-threatening situation requiring immediate attention (modifiers 80 and KX).
•The primary surgeon has a policy of never, without exception, involving a resident in the preoperative, operative, or postoperative care of a patient (modifiers 80 and KX).
•The surgical procedure was complex and required a team of physicians (modifiers 80 and KX).
Use of these modifiers is not required but expedites claims processing. Therefore, it is recommended that these modifiers be used in conjunction with the procedure code rather than a narrative statement when these specific circumstances exist.
All claims for assistant surgeon services must include in Block 32 of the CMS-1500 claim form the name and address or provider identifier of the hospital in which the surgery was performed. If the physician seeks an exception to this TEFRA regulation based on unavailability of a qualified resident, the following certification statement must appear on or 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."
A surgeon billing for a surgery and an assistant surgery fee on the same day (for the same client) may be reimbursed if two separate procedures are performed. Full payment is allowed for the surgery and the assisted surgical procedure is paid at half the allowed amount (16 percent of the TMRM fee for the surgical procedure performed).
Surgical procedures that do not ordinarily require the services of an assistant are denied when billed with a TOS 8 (assistant surgery). Procedures identified by Medicare as noncovered assisted surgical procedures are denied. One assistant surgeon is reimbursed for surgical procedures when appropriate. Two assistant surgeons are allowed for liver transplant surgery only.
Assistant surgeons must have the client's Medicaid number and when required the prior authorization number for claims payment. TMHP recommends that the surgeon provides this information to the assistant surgeon as soon as possible.
Physicians billing for assistant surgery on electronic and paper claims must include a facility provider identifier. When billing for assistant services, providers should bill the most appropriate assistant surgeon modifier.
PAs functioning as an assistant during surgery should be billed on the same claim as the surgery when the PA is not separately enrolled as a provider. Supervising physicians as defined by the Texas Medical Board may bill Medicaid for services performed by the PA they supervise. Use modifier AS for assistant at surgery services rendered by the PA. The claim must include the PA's name and license number. Only procedures currently allowed for assistant surgeons are payable.
PAs actively enrolled as a Medicaid provider with an assigned provider identifier may bill assistant surgery services on a separate claim form using the PA's individual provider identifier and modifiers U7 and 80.
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