Assistant Surgery Coverage and Reimbursement
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This memo governs Blue Cross and Blue Shield of Kansas coverage, reimbursement, and requirements for assistant surgeons (including physician assistants and APRNs) involved at the operating table; it applies to contracting providers billing BCBSKS in Kansas.
No material clinical or coverage changes in this revision.
Assistant Surgeon Coverage Criteria
General coverage
Covered when ALL of the following are met
Multiple assistant surgeons
Covered upon individual consideration when:
Contracting providers agree to accept the review process determination.
Non-physician assistant eligibility
Coverage limited to licensed non-physician assistants when:
IMPORTANT NOTE: If benefits are denied by BCBSKS review, contracting providers agree to forgive charges to members unless a signed waiver exists after the member was informed services may not be covered.
BCBSKS will not make payments for services of a registered nurse or other non-physicians assisting at surgery. This specifically includes Certified Surgical First Assistants (CSFAs). Payments for assistant services are limited to licensed individuals as described elsewhere in the policy.
A list of procedures for which an assistant surgeon is not reimbursed is published online in the BCBSKS provider manual. The list is available at: https://www.bcbsks.com/CustomerService/Providers/Publications/professional/manuals/pdf/assistant_surgery.pdf.
If benefits for assistant surgeon services are denied as not medically necessary by BCBSKS review, contracting providers agree to forgive charges to members unless the member was informed beforehand that such services may not be covered and nevertheless requested them. In that case the member may be charged only if a signed waiver exists documenting the member’s informed request.
Coding and Reimbursement
| No codes listed |
Provider Billing, Documentation, and Actions
Medical necessity and multiple assistants — Assistant surgery is covered if customarily required and medically necessary
Assistant surgery is covered when customarily required and medically necessary; the use of more than one assistant requires individual substantiation and is covered only when medical necessity is demonstrated and accepted through BCBSKS review.
- Assistant surgery covered if customarily required and medically necessary
- More than one assistant surgeon: requires individual consideration and substantiation
Provider notice — action required
Attention providers: review BCBSKS assistant surgery rules before billing — itemize services, confirm licensure of assistants, obtain waivers when patient elects non-covered services, and accept claim review outcomes.
- Itemize assistant surgeon services separately on the claim
- Obtain signed waiver if patient requests non-covered assistant services after being informed
Itemize pre/postoperative services when applicable
When assistant surgeons provide preoperative and/or postoperative care because the operating surgeon is itinerant, pre/postoperative services may be allowed in addition to the assistant surgery fee if clearly explained on the claim. Preoperative and postoperative services must be itemized separately from the assistant surgery fee. If the itinerant surgeon arranges separate pre/postoperative care, the assisting physician should seek payment from the operating surgeon.
- Itemize preoperative and postoperative services separately when billed in addition to assistant surgery
- If the operating (itinerant) surgeon provides or arranges care, seek payment from that surgeon
Denial and waiver — Denial of benefits for assistant surgeon services results from the BCBSKS review process determination
BCBSKS pays only for assistants who are Physician Assistants or Advanced Practice Registered Nurses/Advanced Registered Nurse Practitioners licensed and authorized by Kansas law. Payments are not made for registered nurses or other non-physicians (including Certified Surgical First Assistants). Denial of assistant surgeon services is determined by BCBSKS review; if denied, contracting providers must forgive member charges unless a signed waiver exists for patient-requested non-covered services.
- Payments allowed only for PAs and APRNs/ARNPs licensed in Kansas
- No payment for RNs or other non-physicians, including Certified Surgical First Assistants
- If benefits denied, contracting providers must forgive member charges unless a signed waiver was obtained
Background
Assistant surgery refers to services provided at the operating table by a surgical assistant; mere availability to assist does not constitute assistant surgery. Use of more than one assistant surgeon requires substantiation of medical necessity and is subject to individual consideration under BCBSKS review.
Definitions
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