• 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 is unavailable at the time of the surgery.

  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. Supervising authorized providers that employ NPs may bill as noted for the PA, or the NP 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:

• “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.

Note: Modifiers 80 and 81 are applicable modifiers to use; however, they will most likely require 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 (or does not have) residents and interns on staff (e.g., “small community hospital”).

Surgeon's Services for Multiple Surgeries

Multiple surgery procedures have specific requirements for reimbursement. When multiple surgical procedures are performed, the primary surgical procedure will be paid at 100 percent of the contracted rate. The primary surgical procedure is the surgical procedure with the highest allowable rate. Any additional covered procedures performed during the same surgical session will be allowed 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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