Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 15004, 20702, 21510, 20700, 15002, and 97606 billed 
for date of service May 3, 2022; and procedure codes 15004, 20702, 21510, 20700, 15002, 97606, 15003, 
20701, and 20703 billed for date of service May 6, 2022. We decided that the Plan does not have to pay for 
procedure codes 26445, 15275, 15271, 15276, 20704, 26449 billed for date of service May 3, 2022; and 
procedure codes 20704, 20705, 13160, 26445, 15271, 15272, and 26449 billed for date of service May 6, 2022.  
 
You asked the Plan to pay for the assistant at surgery services billed for dates of service May 3, 2022, and May 
6, 2022. You say that the services are eligible for an assistant. The Plan says that the services are not payable. 
 
We decided that the Plan has to pay for procedure codes 15004, 20702, 21510, 20700, 15002, and 97606 
billed for date of service May 3, 2022; and procedure codes 15004, 20702, 21510, 20700, 15002, 97606, 
15003, 20701, and 20703 billed for date of service May 6, 2022.  
 
The Plan follows Medicare rules. Medicare rules say that modifier AS is billed to indicate that a PA, NP, or 
CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed. 
 
We looked at the file and the rules. The file shows that the assistant at surgery services were provided by a 
physicians assistant. The codes at issue were billed with modifiers 82 and AS. The Plan denied services stating 
modifier 82 should be used by physicians and not physician assistants. Modifiers 82 and AS were billed 
correctly for these codes. Modifier 80, 81 or 82 must also be billed when modifier AS is billed. Therefore, we 
decided that the Plan has to pay for procedure codes 15004, 20702, 21510, 20700, 15002, and 97606 billed for 
date of service May 3, 2022; and procedure codes 15004, 20702, 21510, 20700, 15002, 97606, 15003, 20701, 
and 20703 billed for date of service May 6, 2022.   
 We also decided that the Plan does not have to pay for procedure codes 26445, 15275, 15271, 15276, 
20704, 26449 billed for date of service May 3, 2022; and procedure codes 20704, 20705, 13160, 26445, 
15271, 15272, and 26449 billed for date of service May 6, 2022. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 26445, 15271, 15272, 15275, 15276, and 13160. The Medicare Fee 
Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has 
determined that an assistant surgeon is not medically necessary and will not be paid. Based on this information, 
we decided that the Medicare rules for coverage have not been met. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that codes 20704 and 20705 are add-on codes that have 
not been billed with an appropriate primary procedure code. Based on this information, we decided that the 
Medicare rules for coverage have not been met. 
 
Medicare rules say that providers shall use anatomic modifiers when appropriate. We find that code 26449 was 
not billed with an anatomic modifier as required. Based on this information, we decided that the Medicare rules 
for coverage have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 26445, 15275, 15271, 15276, 
20704, 26449 billed for date of service May 3, 2022; and procedure codes 20704, 20705, 13160, 26445, 15271, 
15272, and 26449 billed for date of service May 6, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.