Assistant Surgery (surgical assistant services)
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Governance of coverage and reimbursement for assistant surgeons and non-physician surgical assistants for Blue Cross and Blue Shield of Kansas providers. Applies to billing, medical necessity determination, and who may be paid as an assistant.
No material clinical or coverage changes in this revision.
Coverage Criteria for Assistant Surgeons
General coverage criteria
Covered when ALL of the following are met
Primary criteria
- Customary billing: Would customarily be billed to the patient regardless of their method of payment
Multiple assistant surgeons
Covered only when substantiated
Contracting providers agree to accept the review process determination
BCBSKS will not make payments for services of a registered nurse or other non-physicians (including Certified Surgical First Assistants) assisting at surgery. This exclusion applies to assistant services when the assistant is an RN or other non-physician not specifically authorized below.
BCBSKS will make payments for assistants only for those persons who are Physician Assistants and Advanced Practice Registered Nurses/Advanced Registered Nurse Practitioners who are licensed and authorized by Kansas law.
Services of RNs and other non-physicians (including Certified Surgical First Assistants) assisting at surgery are not reimbursed and are treated as not medically necessary for payment under this policy.
Coding and Reimbursement
| Physician Assistants | Physician Assistants |
| Advanced Practice Registered Nurses | Advanced Practice Registered Nurses/Advanced Registered Nurse Practitioners |
| Registered Nurse | Registered nurse |
| Certified Surgical First Assistant | Certified Surgical First Assistants |
| Other non-physicians | Other non-physicians assisting at surgery |
Provider Actions, Billing and Documentation
Medical necessity and multi-assistant review
Assistant surgery is covered when customarily required for the procedure due to medical necessity and would customarily be billed regardless of patient payment method. The use of more than one assistant surgeon requires substantiation of medical necessity and is subject to BCBSKS review; contracting providers agree to accept the review determination.
- Assistant surgeons covered when medically necessary and customarily billed
- Multiple assistant surgeons covered only with documented medical necessity and BCBSKS approval
Itemize pre/post-op services when applicable
When assistant surgeons provide preoperative and postoperative care for an itinerant (traveling) operating surgeon, those services may be allowed in addition to the assistant surgery fee if documented on the claim submission. Preoperative and postoperative services must be itemized separately from the assistant surgery fee. If the itinerant surgeon arranges for pre/post-op care, payment should be sought from the operating surgeon.
- Itemize preoperative and postoperative services separately from assistant surgery fee on claims
- Document when operating surgeon is itinerant/traveling and arrangements for pre/post-op care
Denial and member waiver
BCBSKS pays assistants only for Physician Assistants and Advanced Practice Registered Nurses/Advanced Registered Nurse Practitioners licensed and authorized by Kansas law. Payments are not made for registered nurses, Certified Surgical First Assistants, or other non-physicians acting as surgical assistants. If benefits for assistant surgeon services are denied by BCBSKS, contracting providers must forgive charges to members unless the member was informed and signed a waiver requesting the noncovered service.
- Acceptable assistant providers: PA, APRN/ARNP licensed in Kansas
- Not covered: registered nurses, Certified Surgical First Assistants, other non-physicians
- If benefits denied, providers must forgive member charges unless member signed waiver after being informed
Background
Assistant surgery refers to services provided at the operating table by a surgical assistant. The policy distinguishes mere availability to assist from actual assistant surgery performed at the table and requires that assistant services be customarily required for the procedure because of medical necessity. Payment for assistant surgeon services is limited to authorized provider types and is subject to BCBSKS review; denials resulting from that review require contracting providers to forgive charges unless the member signed a waiver after being informed the services may not be covered.
Definitions
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