Currentblue cross blue shield - kansasPolicy N/A

Assistant Surgery

Defines Blue Cross and Blue Shield of Kansas (BCBSKS) policy on coverage and reimbursement for assistant surgeons (physician assistants and APRNs), medical necessity requirements for assistant surgery, pre/postoperative billing when primary surgeon is itinerant, limits on multiple assistants, and exclusions for non-physician personnel.

Policy Summary

Payerblue cross blue shield - kansas

PolicyAssistant Surgery

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen more than one assistant surgeon is used, submit documentation substantiating medical necessity to support coverage; contracting providers must accept the review determination.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Eligible Assistant Types

2Not Eligible

Case-by-caseMultiple Assistants

Policy summary

Assistant Surgery reimbursement and payment rules — CURRENT. Defines Blue Cross and Blue Shield of Kansas (BCBSKS) policy on coverage and reimbursement for assistant surgeons (Physician Assistants and APRNs).

BCBSKS covers assistant surgery only for services provided at the operating table; being available to assist does not constitute assistant surgery.

BCBSKS will make payments only for assistants who are licensed and authorized by Kansas law (Physician Assistants and Advanced Practice Registered Nurses/Advanced Registered Nurse Practitioners); registered nurses and other non-physicians (including Certified Surgical First Assistants) are excluded.

Headline Stats

Eligible Assistant TypesPhysician Assistants and APRNs only

Not EligibleRegistered nurses and Certified Surgical First Assistants excluded

Multiple AssistantsMore than one assistant: case-by-case, covered only with substantiated medical necessity

Reimbursement basisPercentage of the surgical maximum

Coverage stanceMixed

Medical necessity and exclusions

Medical Necessity for Assistant Surgery

Assistant surgery is covered when ALL of the following are met:

Service is customarily required in conjunction with the surgical procedure because of medical necessity
Service would customarily be billed to the patient regardless of their method of payment
Assistant is a person licensed and authorized by Kansas law (Physician Assistant or Advanced Practice Registered Nurse/Advanced Registered Nurse Practitioner) for whom BCBSKS will make payments

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Multiple Assistants

Coverage for more than one assistant surgeon:

Use of more than one assistant surgeon is subject to individual consideration
Coverage only upon substantiation of medical necessity
Contracting providers agree to accept the review process determination

Preoperative and Postoperative Care by Assistant Surgeon

When the operating surgeon is itinerant (traveling):

Preoperative and postoperative care may be allowed in addition to assistant surgery if explained in the submission of claims
Preoperative and postoperative services should be itemized separately from the assistant surgery fee
If the itinerant surgeon makes their own arrangements for pre/postoperative care, payment responsibility is to the surgeon

Excluded Assistants

Registered nurses or other non-physicians (including Certified Surgical First Assistants) assisting at surgery are not eligible for payment

Billing, documentation & operational requirements

Documentation Required

Substantiate medical necessity for multiple assistants

When more than one assistant surgeon is used, submit documentation substantiating medical necessity to support coverage. Contracting providers must accept the review determination for such cases.

Billing Rule

Itemize pre/postoperative services when claiming in addition to assistant surgery

When preoperative and postoperative care is provided in addition to assistant surgery (itinerant surgeon cases), itemize those preoperative and postoperative services separately from the assistant surgery fee in the claims submission. If the itinerant surgeon makes arrangements for pre/postoperative care, payment responsibility is to the surgeon.

Billing Rule

Accept review result and forgive charges if benefits denied

If BCBSKS denies benefits for assistant surgeon services as a result of the review determination, contracting providers agree to forgive charges to BCBSKS members. Exception: if the patient was informed the services may not be covered but requested them anyway and signed a waiver, the provider may charge the patient.

Documentation Required

Waiver when member requests non-covered assistant services

If a patient has been informed that assistant services may not be covered but still requests them, obtain a signed waiver from the member to permit charging the patient for the service.