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Provider Handbook
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Assistant Surgeon Services
Multiple Surgeries
Hospice Pricing |
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Assistant Surgeon Services |
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TRICARE policy defines assistant surgeons as any physician, dentist, podiatrist, certified physician assistant (PA), nurse practitioner (NP), or certified nurse midwife, acting within the scope of their license, who actively assists the operating surgeon in the performance of a covered surgical service. TRICARE covers assistant surgeon services when the services are considered medically necessary and meet the following criteria:
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- The complexity of the surgical procedure warrants an assistant surgeon rather than a surgical nurse or other operating room personnel.
- Interns, residents, or other hospital staff are unavailable at the time of the surgery.
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All assistant surgeon claims are subject to medical review and need verification that the surgical procedure(s) performed required the services of an assistant surgeon and were medically necessary.
Standby assistant surgeon services are not reimbursed when the assistant surgeon does not actively participate in the surgery.
The PA or NP must actively assist the operating surgeon as an assistant surgeon and perform services that are authorized as a TRICARE benefit. When a provider bills for a procedure or service performed by a PA, TRICARE policy requires that the supervising or employing physician bill the procedure or service as a separately identified line item (e.g., PA office visit) and use the PA’s provider number. The supervising or employing physician of a PA must be a TRICARE-authorized provider. NPs may bill on their own behalf and use their NP provider number for procedures or services they perform.
Providers should use the modifier that best describes the assistant surgeon services provided in Column 24D on the CMS-1500 claim form:
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- “Modifier 80” indicates that the assistant surgeon provided services in a facility without a teaching program.
- “Modifier 81” is used for “Minimum Assistant Surgeon” when the services are only required for a short period during the procedure.
- “Modifier 82” is used by the assistant surgeon when a qualified resident surgeon is not available.
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Note: Modifiers 80 and 81 are applicable modifiers to use; however, they will most likely cause a medical review to validate the medical necessity for surgical assistance and medical records may be requested. During this review process, the claim also will be reviewed to validate that this facility has, on file, justification for them not having residents and interns (e.g., “small community hospital”). |
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Multiple Surgeries |
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Multiple surgical procedures have specific requirements for reimbursement. When multiple surgical procedures are performed, the major surgical procedure will be paid at 100 percent of the contracted rate. Any additional procedures involved with the same surgery will be paid at 50 percent of the contracted rate.
An incidental surgical procedure is one that is performed at the same time as a more complex primary surgical procedure. However, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance of the primary procedure. Therefore, no reimbursement will be made for an incidental procedure unless it is required for surgical management of multiple traumas or it involves a major body system different from the primary surgical service.
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Hospice Pricing |
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National Medicare hospice rates will be used for reimbursement of each of the following levels of care provided by, or under arrangement with, a Medicare-approved hospice program:
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- Routine home care
- Continuous home care
- Inpatient respite care
- General inpatient care
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The hospice will be reimbursed for the amount applicable to the type and intensity of the services furnished to the beneficiary on a particular day. One rate will be paid for each level of care except for continuous home care, which will be reimbursed based on the number of hours of continuous care furnished to the beneficiary on a given day. The rates will be adjusted for regional differences by using appropriate Medicare area wage indexes.
The national payment rates are designed to reimburse the hospice for the costs of all covered services related to the treatment of the beneficiary’s terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of, or working under arrangements made with, the hospice. The only amounts that will be allowed outside the locally adjusted national payment rates and not considered hospice services will be for direct patient care services rendered by either an independent attending physician or a physician under contract with the hospice program.
The hospice will bill for its physician charges/services on a UB-04 using the appropriate CPT codes. Payments for hospice-based physician services will be paid at 100 percent of the TRICARE-allowable charge and will be subject to the hospice cap amount (calculated into the total hospice payments made during the cap period).
Independent attending physician services or patient care services rendered by a physician not under contract with or employed by the hospice are not considered a part of the hospice benefit and are not figured into the cap amount calculations. The provider will bill for these services on a CMS-1500 using the appropriate CPT codes. These services will be subject to standard TRICARE reimbursement and cost-sharing/deductible provisions.
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