![]() ![]() Our 3 rd party billing/audit provider sees additional documentation from AAPC which recommends that the primary surgeon also dictate the role of the assistant of surgery. According to CMS and American College of Surgeons documentation, if it is a qualified surgery, the primary surgeon needs to document the use of the assistant – and that would be sufficient to bill. There are guidelines on which surgeries qualify for assistants and when – and we're fine there. The question is the level of documentation that is needed to support billing of assistants at surgery. We have asked and received different views from our MAC. I have a question regarding the documentation practices that others use for Assistant at Surgery. ![]() Subject: Documentation for Assistant at Surgery What level of documentation do you require to bill the assistant at surgery? When asking feedback from our MAC, we have seen both sides supported. Thus the discussion because our 3 rd party would highlight times where this additional documentation is missing as an audit finding.
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