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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an 
assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) 
or clinical nurse specialist (CNS). Medicare uses the payment policy indicators on the Medicare Physician Fee 
Schedule Database (MPFSDB) to determine if assistant at surgery services are reasonable and necessary for a 
specific Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) 
code. The rules say that if the MPFSDB contains an assistant at surgery indicator of 2 for the surgical 
procedure in question, assistant at surgery service may be paid. Payment restrictions do not apply to this 
procedure. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 250.9, 250.9.1, and 250.9.3. 
 
The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an 
assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) 
or a clinical nurse specialist (CNS). Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 
(when qualified resident surgeon not available) is used to bill for assistant at surgery services. When billed 
without modifier AS (PA, NP, or CNS services for assistant at surgery) the use of these modifiers indicate that 
a physician served as an assistant at surgery. 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. Claims submitted 
with modifier AS and without modifiers 80, 81 or 82 are returned to the provider (RTPd). You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 250.9. 
 The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.