Documentation

Assistant at Surgery Billing Documentation Reminder

Claims for assistant at surgery with a zero (0) indicator in the MPFSDB must have information to support and identify the assistant and also support the medical necessity of his/her assistance with the procedure. Listing an assistant on the operative report and making references to “we” and “us” are not sufficient evidence to support medical necessity. There must be a medically valid reason in the operative report for the assistant at surgery for the claim to be paid. If the claim is denied for medical necessity, the appeals process must be followed to submit additional supporting documentation. Claims billed for an assistant at surgery that do not have the assistant listed in the operative report will be denied.

Reviewed 10/27/2022