Assistant Surgeons


For CPT codes with an indicator of 0 (assist only allowed with supporting documentation), how do you recommend the surgeon documents the need for an assistant?

Currently I am seeing the assistant's name documented at the beginning of op note but then no further mention of his role throughout the procedure.

I have several denials where Medicare denied after review of the records. I want to let the surgeons know but am not sure what kind of documentation to suggest.

Thank you!


  • I didn't think that was a possibility-what type of surgery?

  • edited May 2017
    Thoracic Surgery, Specifically VATS with wedge biopsies (32607 and 32608)

  • My physicians use the following verbage:

    An assistant was required to help with exposure of the operative site, allowing the operation to
    be performed in the most safe and expeditious fashion.

  • I try to educate my physicians that they must mention in the body of the note what the assistant helped with and why his expertise was needed as we are a teaching facility. They do not always do this. I have gotten many that state WE rather than I within the note but that still is not always sufficient. They need to say in the note Dr. X assisted with this portion or details.

    Renee R. Antonetti, CPC, CHCO
    Director of Revenue Cycle Management
    Certified Hipaa Compliance Officer
    Alliance Medical Group
    1625 Straits Turnpike, Suite 201
    Middlebury, CT 06762
    Phone: 203-573-9512 ext. 2346
    Fax: 203-575-5204 (please NOTE new fax #)

  • Oh, well maybe then. A bit more involved you most likely will have to appeal it or use the verbiage that was just sent ... looks good

    An assistant was required to help with exposure of the operative site, allowing the operation to be performed in the most safe and expeditious fashion.

  • Great tips everyone, thanks!
  • edited May 2017
    I think that type of statement is to generic. The surgeon needs to be specific to the individual patient issues to support medical necessity for an assistant i.e., due to the patients extreme obesity the assistant was necessary or due to the patients underlying chronic xxxxx an assistant was necessary so that the procedure could be completed as quickly as possible. There has to be some unusual patient specific risk.

  • edited May 2017
    I just reviewed another one for my ortho group where I thought the surgeon DID document well for an ulnar nerve decompression. She stated "Dr. G____ provided valuable retraction and assistance". "We found that..." "Then WE...". WE is all over the op note.

    But then I read your response Jan, and she never really stated WHY it was necessary to have Dr. G there to provide the retraction.

    I am still going to attempt a second level appeal, highlighting all the "WE" statements. We'll see what happens. If they deny again, that's just more "proof" I'll have to show the surgeons they need to be more specific.


  • edited May 2017
    The issue is the procedures that allow an assist only with "special" documentation have already been reviewed by medical specialty societies which have through their expertise determined that under "normal" circumstances the said procedure performed by an appropriately trained surgeon should not need "help". So to bill for an assist there has to be something "special"about this case to get paid for an assist. I don't see that at all in any of the wording you are going on.

  • edited May 2017

    Did the surgeon say why he or she needed the assistant?


  • edited May 2017
    Hi Roy,

    No she didn't. I'm not very optimistic about this appeal but I have already sent education over to the surgeons. Hopefully going forward they will be a lot more specific.


  • They need to be specific why THIS procedure required the use of an assistant. It isn't just what they did or that they were there. That is standard assistant documentation. For those indicating with documentation they are looking for more. Why was this case special. A simple Ortho example is for arthroscopic meniscectomy. Patient size resulted in the leg not fitting in the leg holder therefore an assistant was needed to hold and manipulate the extremity. You also need to show why that couldn't be done by the surgery tech/hospital intra operative staff.

    Ruby Woodward
    Sent from my iPhone

  • edited May 2017

    Some of you many have seen the recent transmittal and MLN Matters, “Common Working File to Locate Medicare Beneficiary Record and Provide Responses to Provider Queries”:

    If I’m reading it right, it says CMS is going to make beneficiary information searchable across nine hosts via the CWF.

    It sounds like it will make verification faster and easier. What do you folks think?


    Roy Edroso
    Part B News
  • Roy:

    It certainly sounds that a practice will find it easier to search beneficiary information provided it is kept up-to-date.


    Maxine Lewis, CMM, CPC, CPC-I, CPMA, CCS-P

    Main: 513-771-7070
    Direct: 513-672-4363

    Fax: 513-326-7640

    200 Northland Blvd

    Cincinnati, OH 45246

  • edited May 2017
    I only have one grief – when we enter the patient’s info and it comes back with ‘Medicare Part C’ it sure would be nice if it gave you the information.

    I bill a lot of nursing home visits and although we have a good relationship with the NH, getting billing information isn’t straight forward and not very timely.

    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059


  • Definitely as long as the information is maintained which I would think since it is CMS based and not third party it should be.

    Ruby Woodward
    Sent from my iPhone

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