Assistant surgeon services

TRICARE policy defines an assistant surgeon as any physician, dentist, podiatrist, certified Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Midwife (CNM) acting within the scope of his or her license who actively assists the operating surgeon with a covered surgical service.

TRICARE covers assistant surgeon services when the services are considered medically necessary and meet the following criteria:

  • The complexity of the surgical procedure warrants an assistant surgeon rather than a surgical nurse or other operating room personnel
  • Interns, residents or other hospital staff is unavailable at the time of the surgery

When billing for assistant surgeon services, please note:

  • All assistant surgeon claims are subject to medical review and medical necessity verification
  • Standby assistant surgeon services are not reimbursed when the assistant surgeon does not actively participate in the surgery
  • The PA or NP must actively assist the operating surgeon as an assistant surgeon and perform services that are authorized as a TRICARE benefit
  • When billing for a procedure or service performed by a PA, the supervising or employing physician must bill the procedure or service as a separately identified line item (e.g., PA office visit) and use the PA’s provider number. The supervising or employing physician of a PA must be a TRICARE-authorized provider
  • Supervising authorized providers that employ NPs may bill as noted for the PA, or the NP may bill on his or her own behalf and use his or her NP provider number for procedures or services performed
  • No payment will be made for an assistant surgeon when co-surgeons are reimbursed. See TRICARE Reimbursement Manual, Chapter 1 for assistance

Providers should use the modifier that best describes the assistant surgeon services provided in column 24D on the CMS-1500 claim form:

  • Modifier 80 indicates that the assistant surgeon provided services in a facility without a teaching program
  • Modifier 81 is used for minimum assistant surgeon when the services are only required for a short period during the procedure
  • Modifier 82 is used by the assistant surgeon when a qualified resident surgeon is not available
  • Modifier AS is used to designate an assistant at surgery

Note: Modifiers 80 and 81 are applicable modifiers to use; however, WPS will most likely wait for medical review to validate the medical necessity for surgical assistance, and medical records may be requested. During this process, the claim also will be reviewed to validate that the facility has (or does not have) residents and interns on staff (e.g., small community hospitals).