CurrentmhnPolicy CC.PP.029

Payment Policy: Assistant Surgeon

Defines payment and coding rules for assistant surgeon services and modifiers (80,81,82,AS) for the Health Plan, describing when assistant surgeon billing is allowed, denied, or reviewed; applies to all product types and affected providers submitting claims.

Policy Summary

Payermhn

PolicyPayment Policy: Assistant Surgeon

Policy CodePolicy CC.PP.029

Change TypeNo material changes

Effective Date01/01/2014

Next Review DateOct 16, 2025

Key ActionClaims with assistant surgeon modifiers are evaluated by code editing software and 'sometimes' codes are reviewed by a specialty physician consultant team to determine payment or denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ALLProduct types covered

3ACS designation categories

4Assistant surgeon modifiers

1Primary guideline source

Assistant Surgeon Coverage and Payment Criteria

Assistant Surgeon coverage criteria

Policy Summary

Payermhn

PolicyPayment Policy: Assistant Surgeon

Policy CodePolicy CC.PP.029

Change TypeNo material changes

Effective Date01/01/2014

Next Review DateOct 16, 2025

Key ActionClaims with assistant surgeon modifiers are evaluated by code editing software and 'sometimes' codes are reviewed by a specialty physician consultant team to determine payment or denial.

SourceLink

On This Page

Assistant Surgeon billing and payment determinations follow ACS procedure designation categories (Almost Always, Sometimes, Almost Never) with CMS designations referenced for certain statistical/payment restrictions.

ALMOST ALWAYS: Procedures ACS designates as 'Almost Always' are allowed for reimbursement when billed with assistant surgeon modifiers.

ALMOST NEVER: Procedures ACS designates as 'Almost Never' are not allowed for reimbursement when billed with assistant surgeon modifiers.

SOMETIMES: Procedures ACS designates as 'Sometimes' are evaluated by code editing software and reviewed by a specialty physician consultant team; based on consultant consensus the code will be assigned 'Sometimes' or 'Never' and paid or denied accordingly.

CMS CROSS-CHECK FOR 'SOMETIMES' CODES: If CMS designates a code that ACS lists as 'Sometimes' as 'Never', the specialty physician consultant team will typically adopt the CMS 'Never' designation because CMS uses statistical data; such claim lines are denied unless the consultant team documents a different clinical justification.

Automated code editing software identifies procedure codes submitted with assistant surgeon modifiers for review and triggers specialty consultant review where indicated.

Payment remains subject to applicable plan contract terms, state/federal requirements, and administrative policies; Medicare/Medicaid-specific rules may supersede where applicable.

Modifiers and Coding Rules for Assistant Surgeon Services

Assistant Surgeon ModifiersModifier

80	Assistant Surgeon
81	Minimum Assistant Surgeon
82	Assistant when qualified resident not available
AS	Assistant performed by PA/NP/CNS

Coding Reference Notemixed

CPT	This payment policy references Current Procedural Terminology (CPT®). Codes referenced are informational; inclusion or exclusion does not guarantee coverage.

Sometimes-category evaluation (inv-03)

Evaluation process for 'Sometimes' codesCodes designated 'Sometimes' by ACS are flagged by code editing software and compared with CMS designations; they are reviewed by a specialty physician consultant team that assigns a final designation ('Sometimes' or 'Never') and determines payment or denial.

CMS 'Never' cross-check and denial conditionIf CMS designates a code as 'Never' while ACS designates it 'Sometimes', the specialty consultant team defers to CMS statistical designation and such claim lines are typically denied unless review finds otherwise.

Role of CMS designationCMS designations are based on billing frequency/statistical data rather than clinical circumstance and are used as a presumptive restriction when conflicting with ACS 'Sometimes' listings.

Exception via specialty physician reassignmentThe specialty physician consultant team may reassign an ACS 'Sometimes' code to 'Sometimes' or 'Never' based on consultant consensus; reassignment governs payment outcome.

Claim Review and Provider Billing Actions

Prior Authorization

Code editing plus specialty physician consultant review for 'Sometimes' codes

Claims submitted with assistant surgeon modifiers are screened by the Health Plan's code editing software which identifies procedure codes inappropriately billed with an Assistant Surgeon modifier; codes ACS designates as 'sometimes' are escalated for specialty physician consultant review comparing ACS and CMS designations to determine payment or denial.

Code editing software evaluates claim lines and flags potentially inappropriate assistant surgeon modifier use.
Procedures ACS designates as 'Sometimes' are reviewed by a physician consultant team within the appropriate surgical specialty; the team assigns a final designation ('Sometimes' or 'Never') and issues payment or denial.
If CMS designates a code as 'Never' while ACS designates it 'Sometimes', the specialty consultant uses the CMS designation (based on CMS statistical data) and those claim lines are denied unless consultant consensus assigns otherwise.

Key Definitions

Definition of Assistant Surgeon (inv-05)

DefinitionA trained individual who participates in and actively assists the surgeon to complete the operation safely and expeditiously by providing exposure, maintaining hemostasis, and other technical functions; may be a qualified surgeon, resident, or non-physician practitioner.

Source guidancePolicy adopts American College of Surgeons (ACS) definitions and procedure designations (Almost Always / Sometimes / Almost Never) to determine appropriate assistant surgeon use.

Who may serve as assistantAssistants at Surgery may be a qualified surgeon, a resident in an approved surgical education program, or in some cases a non-physician practitioner (e.g., PA/NP/CNS).

Modifiers 80/81/82/AS (inv-06)

Modifier 80Assistant Surgeon (primary definition for an assistant surgeon).

Modifier 81Minimum Assistant Surgeon.

Modifier 82Assistant when qualified resident surgeon not available.

Modifier ASIndicates a PA, NP, or CNS served as the assistant at surgery.