Subject:
Assistants at Surgery
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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An assistant at surgery actively assists the operating surgeon in the performance of a surgical procedure.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. An assistant at surgery will be considered medically necessary based on the complexity of the surgical procedure(s).
2. Services of an assistant at surgery must be requested by the operating surgeon.
3. A registered nurse first assistant (RNFA) is a registered nurse (RN) who is licensed in the state in which he or she practices and permitted to serve as a first surgical assistant in major surgical procedures provided he or she is duly qualified by a hospital's credentialing committee. The RNFA will be compensated by Horizon BCBSNJ if not compensated by the hospital or other facility provided that the procedure is one for which an assistant is considered medically necessary.
4. Assistant at surgery services provided by a physician assistant (PA) are eligible for reimbursement provided that the procedure is one for which an assistant at surgery is considered medically necessary, and the service is submitted under his or her physician employer's provider (or tax identification) number.
5. Assistant at surgery services provided by surgeons-in-training (i.e., residents) or non-physicians (e.g., surgical nurses and surgical technicians) other than RNFAs and PAs are not eligible for reimbursement by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ).
6. The following is a list of CPT and HCPCS procedure codes in which an assistant at surgery is NOT considered medically necessary.
 AS Not Medically Necessary 2020.docx
Medicare Advantage Coverage:
See Informational Note below.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
[INFORMATIONAL NOTE: The above list of codes is based on Change Healthcare's Clinical Department 's review of relevant information developed by coding authorities such as the American Medical Association (AMA), the American College of Surgeons (ACS), the Centers for Medicare and Medicaid Services (CMS) and others. Change Healthcare uses the American College of Surgeons as its primary source for determining assistant surgeon designations. This rationale is based on the fact that the ACS determines these designations using clinical guidelines versus statistical measures. In contrast, the CMS assistant surgeon reimbursement policy is based solely on the frequency (via a national sample) in which a specific procedure is reported with an assistant surgeon modifier. Consequently, clinical logic is not used for the CMS determination of designations for assistant surgeon.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Assistants at Surgery
Assistant Surgeon
Assistant, Physician
Nurse, Surgical
Physician Assistant
Registered Nurse First Assistant
Residents, Surgical
RNFA
Surgeon, Assistant
Surgical Nurse
Surgical Resident
Surgical Technician
Technician, Surgical
References:
1. McKesson Corporation. ClaimsXten Auditing Logic and Rules Guide.
2. American College of Surgeons (ACS) and other surgical specialty organizations. Physicians as Assistants at Surgery: 2013 Study.
3. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Manual: Assistant at Surgery.
4. Change Healthcare. ClaimsXten Auditing Logic and Rules Guide.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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