CurrentBaylor Scott & White Health PlanPolicy 248

Assistant Surgeon Policy

Defines when Baylor Scott & White Health Plan (BSWHP) will reimburse assistant surgeon services based on CMS National Physician Fee Schedule (NPFS) assistant surgeon payment indicator and additional restrictions for provider types and non-contracted practitioners.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAssistant Surgeon Policy

Policy CodePolicy 248

Change TypeUpdate Medicare exclusions

Effective DateMay 1, 2026

Next Review DateMar 26, 2027

Key ActionObtain prior authorization when a non-contracted practitioner seeks reimbursement for assistant surgeon services; submit written appeal with medical necessity documentation for codes with CMS indicator '0'.

SourceLink

POLICY UPDATE CHANGES

Updated Medicare exclusions.

Indicator-basedEligibility Determination Method

4Assistant Modifiers Recognized

3Medicare-Excluded Provider Types

Coverage Summary & Scope

Defines when Baylor Scott & White Health Plan (BSWHP) will reimburse assistant surgeon services: BSWHP follows the CMS National Physician Fee Schedule (NPFS) assistant surgeon payment indicators and will consider assistant surgeon reimbursement when the CPT code's CMS NPFS Assistant Surgeon Indicator is 2 and the service is reported with an assistant surgeon modifier (80, 81, 82, or AS). BSWHP will not reimburse non-contracted practitioners for assistant surgeon services unless prior authorization has been obtained. Additionally, CPT codes with indicators 0, 1, or 9 are not eligible for assistant surgeon reimbursement on initial adjudication (codes with indicator 0 may be appealed with supporting documentation).

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Reimbursement Criteria

Reimbursement Eligibility for Assistant Surgeon Services

Assistant surgeon services are reimbursable when the following CMS NPFS payment indicator conditions are met and provider requirements are satisfied:

ALL of the following

CPT code has CMS NPFS Assistant Surgeon Indicator = '2' (Payment restriction for assistants at surgery does not apply; assistant at surgery may be paid).
Assistant surgeon services are identified on the claim with an assistant surgeon modifier: 80, 81, 82, or AS.
Assistant surgeon is a contracted provider with BSWHP, or if non-contracted, prior authorization for that provider has been procured for assistant surgeon reimbursement.
BSWHP will NOT reimburse non-contracted practitioners seeking payment as an assistant surgeon unless prior authorization obtained.
Eligible provider types (implicit)
- ANY of the following
  - Physician assistant, nurse practitioner, or clinical nurse specialist when billed with modifier AS.
  - Physician assistant/resident exceptions when billed with appropriate modifier 82 (when qualified resident surgeon not available).
  - Physician assistant/resident exceptions when billed with modifier 81 (minimum assistant).

Not Eligible for Assistant Surgeon Reimbursement on Initial Adjudication

ANY of the following

CPT code has CMS NPFS Assistant Surgeon Indicator = '0' (NOT eligible on initial adjudication).
Claims with indicator '0' may be reviewed for reimbursement upon written appeal with documentation supporting medical necessity for the assistant surgeon.
CPT code has CMS NPFS Assistant Surgeon Indicator = '1' (NOT eligible).
CPT code has CMS NPFS Assistant Surgeon Indicator = '9' (NOT eligible).

Medicare Provider Type Exclusions

Medicare does not reimburse the following provider types for assistant at surgery service:

ANY of the following

Certified First Assistant (CFA)
Certified Surgical First Assistant (CSFA)
Certified Surgical Assistant (CSA)

Relevant Codes & Indicators

Assistant Surgeon Modifiers (used to identify assistant surgeon services)Modifier

80	Assistant surgeon
81	Minimum assistant surgeon
82	Assistant surgeon (when qualified resident surgeon not available)
AS	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

CMS NPFS Assistant Surgeon Indicator Values (used to determine reimbursement eligibility)mixed

Indicator=2	Payment restriction for assistants at surgery does not apply; assistant at surgery may be paid (eligible for reimbursement by BSWHP).
Indicator=0	Not eligible for assistant surgeon reimbursement upon initial adjudication; may appeal with documentation of medical necessity.
Indicator=1	Not eligible for assistant surgeon reimbursement.
Indicator=9	Not eligible for assistant surgeon reimbursement.

Billing, Authorization & Documentation

Prior Authorization

Prior authorization for non-contracted assistant surgeons

Obtain prior authorization when a non-contracted health care practitioner seeks reimbursement for assistant surgeon services using modifiers 80, 81, 82, or AS; claims from non-contracted providers will not be reimbursed unless prior authorization has been procured.

Affected modifiers: 80, 81, 82, AS

Documentation Required

Appeal documentation for Indicator=0 codes

If a CPT code has CMS assistant surgeon indicator '0', submit a written appeal with documentation supporting medical necessity to request reimbursement; initial adjudication will deny assistant reimbursement for these codes.

Indicator=0 initial adjudication denial — submit written appeal with medical necessity documentation.

Billing Rule

Use of assistant surgeon modifiers

Report assistant surgeon services with the appropriate modifier (80, 81, 82, or AS) to be considered for reimbursement when CMS NPFS indicator allows payment.

Policy Background & Definitions

Background: BSWHP uses the CMS NPFS assistant surgeon payment indicators to determine reimbursement eligibility and recognizes modifier use to identify assistant services—Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), 82 (assistant when qualified resident not available), and AS (physician assistant, nurse practitioner, or clinical nurse specialist). This policy follows CMS guidance and does not supersede benefit plan terms or federal/state mandates; the applicable benefit plan document and any controlling federal or state rules take precedence.

Term	Definition
Assistant Surgeon Indicator '2'
CMS NPFS code meaning 'Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.'
Modifier 80
Assistant surgeon
Modifier 81
Minimum assistant surgeon
Modifier 82
Assistant surgeon (when qualified resident surgeon not available)
Modifier AS
Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

Document Changes

2018-06-05created

New policy created.

2019-08-22reviewed

Policy reviewed; no changes.

2020-09-24reviewed

Policy reviewed and re-formatted for SWHP/FirstCare.

2021-12-23reviewed

Policy reviewed; no changes.

2022-12-29reviewed

Policy reviewed; no changes.

2024-03-11reviewed

Formatting changes; beginning and ending note sections updated to align with CMS requirements and business entity changes.

2024-08-12reviewed

Policy reviewed; no changes.

2025-01-13reviewed

Ending note section updated to align with business entity changes.

2026-03-26revised

Updated Medicare exclusions.

2026-05-01effectiveLatest

Policy effective date.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAssistant Surgeon Policy

Policy CodePolicy 248

Change TypeUpdate Medicare exclusions

Effective DateMay 1, 2026

Next Review DateMar 26, 2027

SourceLink

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