Answer: After additional reviews, Palmetto GBA has modified guidance regarding documentation requirements for assistants at surgery or surgical assistants (billed with HCPCS modifier AS and CPT modifiers 80, 81 or 82).

To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant.

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