Assistant Surgeon Services
Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.
• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.
Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.
Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.
Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.
Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.
Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.
Procedures
Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.
First Assistant in Surgery
Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.
Reimbursement
• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.
• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.
• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.
