(Medicare Claims Processing Manual)

250.8.2 - Coding for the Administration of Other Drugs and Biologicals  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  Outpatient physician involvement for hydration; therapeutic or diagnostic injections and intravenous (IV) infusions (other than hydration); and chemotherapy administration in a Method II CAH is included in the physicians evaluation and management (E & M) services. Bills must include an appropriate outpatient hospital visit E & M CPT code with revenue code 96X, 97X or 98X on TOB 85X.   See 250.2 for information on fee schedule payment for professional services.   250.9 - Coding Assistant at Surgery Services Rendered in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  An assistant at surgery is a physician or non- physician practitioner who actively assists the physician in charge of the case in performing a surgical procedure.   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).   Assistant at surgery services rendered by a physician or non- physician practitioner that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and an appropriate assistant at surgery modifier.   Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes.  This includes the use of payment modifiers for assistant at surgery services.   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 modifier 80, 81 or 82 are returned to the provider (RTPd).   250.9.1 - Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Assistants at Surgery  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  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, PA, NP or a CNS.  Section 1862 of the Act stipulates that no payment can be made for care that is not reasonable and necessary.  Specifically, Section 1862(15)(A) addresses services of an assistant at surgery and when those services are statutorily excluded.   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 HCPCS/CPT code.  The MPFSDB is located at http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/PFSlookup/ .  Since all of the information housed on the MPFSDB is not needed to process Method II CAH claims, the payment policy indicators that are needed are extracted on a quarterly basis for use in processing these claims and sent to the fiscal A/B MACs (A)  on the Physician Fee Schedule Payment Policy Indicator File.   See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the assistant at surgery payment policy indicators.   250.9.2 - Payment of Assistant at Surgery Services Rendered in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  Under Section 1834(g)(2)(B) of the Social Security Act (the Act) outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient  CAH services.   Section 1848(i)(2)(B) of the Act stipulates that in the case of a surgical service furnished by a physician, if payment is made separately under the Act for the services of a physician serving as an assistant at surgery, payment shall not exceed 16 percent  of the MPFS amount.  Payment for assistant at surgery services performed by a physician is calculated as follows:    ((facility specific MPFS amount times assistant at surgery reduction % (16%)) minus (deductible and coinsurance)) times 115%   Section 1833(a)(1)(O)(ii) of the Act states that in the case of a PA, NP or CNS the amounts paid for serving as an assistant at surgery shall be the lesser of the actual charge or 85 percent of the amount that would otherwise be recognized if performed by a physician who is serving as an assistant at surgery.  The payment methodology for these services has been codified in regulations found at 42 CFR 414.52(d) and 414.56(c).   Payment for assistant at surgery services performed by a PA, NP, or CNS is calculated as follows:   ((facility specific MPFS) amount times assistant at surgery reduction (16%) times non -physician practitioner reduction % (85%)) minus (deductible and coinsurance)) times 115%   250.9.3 - Assistant at Surgery Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  (Rev. 3475, Issued: 03- 04-16, Effective: 06 -06-16, Implementation: 06- 06-16)  Contractors shall deny  medically unnecessary assistant at surgery services for HCPCS/CPT codes with a payment policy indicator of 0 or 2 when an Advance Beneficiary Notice (ABN) was issued.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 54  RARC: N/A  MSN: 36.1  Contractors shall deny medically unnecessary assistant at surgery services for HCPCS/CPT codes with a payment policy indicator of 0 or 2 when an ABN was not issued.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 36.2  Contractors shall deny assistant at surgery services for HCPCS/CPT codes with a payment policy indicator of 1.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.11  250.9.4 - Assistant at Surgery Services in a Method II CAH Teaching Hospital  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  Section 1842(b)(7)(D) stipulates that no payment shall be made for the services of assistant at surgery with respect to a surgical procedure if a hospital has a training program relating to the medical specialty required for the surgical procedure and a qualified individual on the staff of the hospital i s available to provide such services.   A/B MACs (A) process assistant at surgery claims for services furnished in a teaching hospital through the use of modifier 82 which indicates that a qualified resident was not available.  Modifier 82 is for use only when the basis for payment is the unavailability of qualified residents.   Payment may be made for the services of assistants at surgery in teaching hospitals not withstanding the availability of a qualified resident to furnish the services. There may be exceptional medical circumstances (emergency, life threatening situations su ch as multiple traumatic injuries) which require immediate treatment. There may be situations in which the medical staff may find that exceptional medical circumstances justify the services of a physician assistant at surgery even though a qualified reside nt is available.   Payment may also be made for the services of assistants at surgery in teaching hospitals, if the primary surgeon has an across -the-board policy of never involving residents in the preoperative, operative, or postoperative care of his or her patients.   Claims submitted by a Method II CAH teaching hospital on type of bill 85X with RC 96X, 97X or 98X and modifier AS, 80 or 81 are suspended for review by the A/B MAC (A) when the HCPCS/CPT code has a payment policy indicator of 0 or 2.  NOTE:  Teaching hospitals are identified by an intern to bed ratio greater than 0 (zero), this field is located on the Provider Specific File.   250.9.5 - Review of Supporting Documentation for Assistant at Surgery Services in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  Given the absence of national policy on this provision, A/B MACs (A) have the authority to establish procedures to define the appropriate supporting documentation needed to establish medical necessity, the existence of exceptional medical circumstances or to determine if the primary surgeon has an across -the-board policy of never involving residents in the preoperative, operative or postoperative care of his patients for assistant at surgery services.  The A/B MACs (A) shall also determine if a clinician or  non-clinician medical reviewer shall review assistant at surgery services.   250.10 - Coding Co- surgeon Services Rendered in a Method II CAH  (Rev. 1781, Issued: 07- 29-09; Effective:  01 -01-08; Implementation:  07 -06-09)  Under some circumstances, the skills of two surgeons (each in a different specialty) are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the pa tients condition.  Co-surgery refers to a single surgical procedure which requires the skill of two surgeons, each in a different specialty, performing parts of the same procedure simultaneously. It is not always co -surgery when two doctors perform surgery on the same patient during the same operative session. Co -surgery has been performed if the procedure(s) performed is part of and would be billed under a single surgical procedure code.   When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon shall report his/her distinct operative work by reporting the same surgical procedure code and the 62 modifier (two surgeons).  The potential exists that there may only be one line billed on a Method II CAH claim with modifier 62. This occurs when one of the co- surgeons reassigns their billing rights to the CAH and the other co- surgeon does not reassign their billing rights to the CAH. The claim for the co -surgeon that reassigned their billing rights would be processed by the A/B MAC (A).   The claim for the co -surgeon that did not reassign their billing rights to the CAH would be processed by the A/B MAC (B).  The A/B MAC (A) standard system (FISS) will accept and process claims with one line with a surgical procedure code and modifier 62 or two lines with the same surgical procedure code, line item date of service (LIDOS) and modifier 62.  The FISS shall deny line items without the 62 modifier on claims with the same surgical procedure code and LIDOS when only one line has the 62 m odifier.   Co-surgeon services rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized for co -surgeons and is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and the 62 modifier.   Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for co -surgeon services.  250.10.1 - Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Co -surgeons  (Rev. 1781, Issued: 07- 29-09; Effective:  01 -01-08; Implementation:  07 -06-09)