Surgical Assistance Fees

This module is a general guideline on billing surgical assistance fees. For greater details, refer to Preamble D. 5. 4. and the Sectional Preamble related to your specialty in the Medical Services Commission Payment Schedule.

Note i:Assistant Fees are not payable when the procedure performed is prefixed by the letter (S).
              S – Designates fee items for which a surgical assistant’s fee is not payable.

Note ii:If medically required, Certified Surgical Assistant fees are billable without a written explanation from the surgeon when the procedure performed is prefixed by the letter (C).
             C – Designates fee items for which it is not required to indicate by letter the need 
                   for a certified surgeon to assist at surgery (see fee item 70019).

Note iii: The dollar values and percentages quoted in this module reflect the rates as of April 01, 2013 and are subject to change in the future.

Fee items 00195, 00196 and 00197 are billable by all specialties that have the qualifications to assist at surgical procedures. Payment is based on the value of the total operative fee(s) that is paid to the operating surgeon.

Description of the General Surgical Assistance listings:

00195 less than $317.00 inclusive $131.64
00196 $317.01 to 529.00 inclusive $185.59
00197 over $529.00 $243.04
00198 Time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof $27.80

Below are some examples of payment based on the surgical fee(s) paid to the surgeon:

Fee item V07475 (partial Axillary dissection) $232.77 Fee item 00195
Fee item V07472 (total Mastectomy) $465.01 Fee item 00196
Fee item V70479 (radical Mastectomy) $762.62 Fee item 00197
Fee items V07472 (100%-$465.01) and V07475 (50%-$116.39) the total of the two surgical fees equal $581.40         Fee item 00197

Preamble D. 5. 4. i.

Time, for the purposes of fee codes 00193, 00198, 70020, 07920 etc. is calculated from the time of the surgical assistant’s first contact with the patient in the operative suite.

Fee item 00193 Non-CVT-certified assistance at open-heart surgery, per quarter hour or major portion thereof $28.11
Fee item 00198 Time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof $27.80
Fee item 70020 Time, after 1 hour of continuous certified surgical assistance for one patient, up to and including 3 hours of continuous surgical assistance, each 15 minutes or fraction thereof $26.28
Fee item 07920 Time, after 4 hours of continuous surgical assistance for one patient each 15 minutes or fraction thereof $21.24

Example 1:
Fee item 07853 (mitral valve, commissurotomy - $1,394.63) is performed. The surgical assistant time is from 0800hrs. to 1200hrs., payment would be:
16 x fee item 00193 (non-CVT-certified surgical assistance at open-heart surgery, per quarter hour or major portion thereof).

Example 2:
Fee item C06159 (tram flap reconstruction of mastectomy defect - $1,002.09) is performed. The surgical assistant time is from 0800hrs. to 1210hrs., payment would be:
From 0800hrs. to 0900hrs.,1 x fee item 70019 (Certified surgical assistant).
From 0900hrs. to 1100hrs.,8 x fee item 70020 (time, after one hour of continuous certified surgical assistance for one patient, up to and including 3 hours of continuous surgical assistance, each 15 minutes or fraction thereof).
From 1100hrs. to 1210hrs.,5 x fee item 00198 (time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof).

Example 3:
Fee item 03161 (posterior laminectomy for localized spinal stenosis, two levels or less -$773.94) is performed.  The surgical assistant time is from 0800hrs. to 1135hrs., payment would be:
From 0800hrs. to 1100hrs., 1 x fee item 00197 (surgical assistance at surgery/surgeries over $529.00).
From 1100hrs. to 1135hrs., 3 x fee item 00198 (time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof).

Example 4:
Fee item 03161 (posterior laminectomy for localized spinal stenosis, two levels or less -$773.94) is performed.  The surgical assistant time is from 0800hrs. to 1100hrs.
Only 1 x fee item 00197 is payable.

Example 5:
Fee item 07868 (atrial septum defect, patch - $1394.63) is performed.  The surgical assistant time is from 0800hrs. to 1230hrs., payment would be:
From 0800hrs. to 1200hrs., 1 x fee item 07917 (first assistant for operations over $1033.00).
From 1200hrs. to 1230hrs., 2 x fee item 07920 (time, after 4 hours of continuous surgical assistance for one patient, each 15 minute period or fraction thereof).

Preamble D. 5. 4. ii.

When two or more surgeries are performed under the same anaesthetic requiring repositioning or re-draping of the patient or more than one separately draped surgical operating field is required, separate assistant fees may be claimed for each operation, except for bilateral procedures, procedures within the same body cavity or procedures on the same limb.

Example 1 - The operations performed are:

Fee item V70479 (radical mastectomy) $762.62
Fee item 06018 (removal of tumour, including intraoral – more than 10 cm) $443.84

*Information provided is that fee item 06018 is performed on the back and the tumour size is 12 cm*
In accordance with Preamble D. 5. 3. ii., fee items V70479 at 100% ($762.62) and 06018 at 75% ($332.88) are payable to the surgeon.
If assistance is required at both procedures, 1 x fee item 00197 is payable for the procedure on the breast and 1 x fee item 00196 is payable for the procedure on the back, as the second procedure would require a separate incision , repositioning and re-draping.

Example 2 - The operations performed are bilateral mastectomies:

Fee item 2 x V07472 (total, for malignancy) $465.01

In accordance with Preamble D. 5. 3. i., 2 x fee item V07472 is payable at 150% ($697.52) to the surgeon. Only 1 x fee item 00197 is payable as this is a bilateral procedure.

Example 3 - The operations performed are:

Fee item V07636 (resection of small intestine) $591.73
Fee item V07627 (gastrojejunostomy) $425.82

In accordance with Preamble D. 5. 3. i., fee items V07636 at 100% ($591.73) and 07627 at 50% ($292.91) are payable to the surgeon.
Only 1 x fee item 00197 is payable as the procedures performed are in the same body cavity.

Example 4 - The operations performed are on the left arm:

Fee item 52735 (O.R.I.F - two parts of the proximal humerus) $531.06
Fee item 53765 (O.R.I.F. of the radius and ulna shaft) $531.06

In accordance with Preamble D. 6. a., fee items 52735 and 53765 are both payable at 100% to the surgeon. Only 1 x fee item 00197 is payable as the surgery is performed on the same limb.

Preamble D. 5. 4. iii.

If, in the interest of the patient, the referring medical practitioner is requested by the patient or the surgeon to attend but does not assist at the procedure, attendance at surgery may be claimed as a subsequent hospital visit.

Preamble D. 5. 4. iv.

“C” – designates fee items for which it is not required to indicate by letter the need for a certified surgeon to assist at surgery (see fee item 70019).
The Certified Surgical Assistant fees apply to surgical procedures prefixed by the letter “C”.  When the procedures performed are not “C” prefixed, an explanation outlining the unusual technical difficulties unique to the patient must be submitted by the operating surgeon and independent consideration will be given to each case.  Otherwise, the general assistant listings are applicable to all other situations where surgical assistance is necessary.

Example 1 - The operation performed is:

Fee item V70720 (cholecystoenterostomy with gastroenterostomy) $853.81

Fee items 70019 x 1 and 70020 (from 1200hrs. to 1330hrs.) are billed by the assistant.
The operating surgeon has not provided an explanation outlining the unusual technical difficulties unique to the patient. Fee item 70019 would be reduced to fee item 0197 with explanatory code QS QJ and fee item 70020 would be refused with explanatory code QS as fee item 70020 is only payable in conjunction with fee item 70019.
QS (70019/70020 requires confirmation of medical necessity from the surgeon.)
QJ (Adjusted to agree with the surgical/assist fee item paid for this date of service.)

Example 2 - The operation performed is:

Fee item V70720 (cholecystoenterostomy with gastroenterostomy)  $853.81

The patient has massive adhesions due to Crohn’s Disease and the operating surgeon has indicated this in a note record on the claim submission or in a letter.
In this case the massive adhesions would cause unusual technical difficulty for the surgery. Therefore; fee item 70019 is payable.

Example 3 -The operation performed is:

Fee item V70720 (cholecystoenterostomy with gastroenterostomy)  $853.81

The patient is morbidly obese with a Body Mass Index of 45 and the operating surgeon has indicated this in a note record on the claim submission or in a letter.
Fee item 70019 is payable.
Hint: When a Certified Surgical Assist is requested due to morbid obesity, the patient’s BMI must be provided for independent consideration.

Preamble D. 5. 4. v.

Where surgery is abandoned, independent consideration will be given to the fee applicable to the assistant, to a maximum of 50 percent of the listed assistant fee for the intended procedure.

Example:
The patient was undergoing a hysterectomy operation (fee item 04228 at $569.80) and had a myocardial infarction necessitating resuscitation. The surgery was abandoned due to the patient’s poor health.
A percentage of fee item 00197 would be paid based on the information provided.
Hint: An operative report should be submitted to facilitate payment.

In addition to the general guideline regarding assistance fees, the following fees have specific criteria for billing purposes:

For Diagnostic and Therapeutic Procedures
Fee item 00845 (cardiology assist for first hour or fraction thereof)
Fee item 00846 (after one hour, for each 15 minutes or fraction thereof)
The above fees are only applicable for cardiovascular diagnostic and selected therapeutic procedures; these fees are not billable when open heart surgery is performed.

Example:
Fee item 50555 (percutaneous transcatheter cardiac occluder device closure of ASD in pediatric patients (0-18yr) - composite fee) is performed, the surgical assistant time is from 0800hrs. to 1100hrs. Payment would be:
From 0800hrs. to 0900hrs., 1 x fee item 00845 (cardiology assist for first hour or fraction thereof).
From 0900hrs. to 1100hrs., 8 x fee item 00846 (after one hour, for each 15 minutes or fraction thereof).
 
For Obstetrics and Gynecology
Fee item G04710 (gynecological certified surgical assistant-for up to one hour)
Fee item G04711 (gynecological certified surgical assistant, time after one hour of continuous certified surgical assistance for one patient, up to and including 3 hours of continuous time - each 15 minutes or fraction thereof)
Fee item G04712 (gynecological certified surgical assistant (certified or second), time after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof)
Fee item G04713 (laparoscopic hysterectomy second surgical assistant - paid only with G04709)
The above fees are restricted to Obstetrics and Gynecology specialists.
Fee items G04710, G04711 and G04712 are only payable when billed in conjunction with either fee items G04705, G04707 or G04709
Fee item G04713 is only payable when billed in conjunction with fee item G04709.

Example:
Fee item G04709 (laparoscopic total or supracervical hysterectomy, and/or laparoscopic assisted vaginal hysterectomy (LAVH) - includes oophorectomy and/or salpingectomy) is performed, the surgical assistant time is from 0800hrs to 1215hrs and two certified assists are required. Payment would be:
For the first certified assistant:
From 0800hrs. to 0900hrs., 1 x fee item G04710 (gynecological certified surgical assistant-for up to one hour).
From 0900hrs. to 1100hrs., 8 x fee item G04711 (gynecological certified surgical assistant, time after one hour of continuous certified surgical assistance for one patient, up to and including 3 hours of continuous time - each 15 minutes or fraction thereof).  
From 1100hrs. to 1215hrs., 5 x fee item G04712 (gynecological certified surgical assistant (certified or second), time after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof).

For the second certified assistant:
From 0800hrs. to 1100hrs., 1 x fee item G04713 (laparoscopic hysterectomy second surgical assistant - paid only with G04709).
From 1100hrs. to 1215hrs., 5 x fee item G04712 (gynecological certified surgical assistant (certified or second), time after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof).

For Cardiac Surgery
The fees below are only billable in conjunction with open heart surgical fees.
Fee item 00193 (non-CVT-certified surgical assistance at open-heart surgery, per quarter hour or major portion thereof).
Note: The same fee applies equally to all assistants. (first, second, etc.)

Specially Qualified Assistant fees
Fee item 07915 (first assistant for operations of $1,033.00, or less)
Fee item 07916 (second and third assistant for operations of $1,033.00, or less) 
Fee item 07917 (first assistant for operations over $1,033.00)
Fee item 07918 (second and third assistant for operation over $1,033.00)
Fee item 07920 (time, after four hours of continuous surgical assistance for one patient, each 15 minute period or fraction thereof)

Example:
Fee item 07859 (aortic valve replacement - $1,556.00) is performed and 2 assistants were medically required in this case, the surgical assistant time is from 0800hrs. to 1215hrs.
Payment would be as follows:
For a specially qualified first assistant
From 0800hrs. to 1200hrs., 1 x fee item 07917 (first assistant for operations over $1,033.00).
From 1200hrs. to 1215hrs., 1 x fee item 07920 (time, after four hours of continuous surgical assistance for one patient, each 15 minute period or fraction thereof).

For a non-CVT – certified assistant
17 x fee item 00193 (Open Heart Surgery - Non-CVT-certified surgical assistance at open-heart surgery, per quarter hour or major portion thereof)
Note: The same fee applies equally to all assistants (first, second, etc.).

For Orthopaedics and Urology
For the above sections, an additional fee for the first surgical assist of the day may be billable if the following criteria are met:
Fee item 51194 (first Surgical Assist of the day)
i)  Restricted to orthopaedic surgeons.                                        
ii) Maximum of one per day per physician, payable in addition to fee items 00195, 00196 and 00197.

Fee item 81194 (first Surgical Assist of the day)
i)  Restricted to urology surgeons.                                             
ii) Maximum of one per day per physician, payable in addition to fee items 00195, 00196 and 00197.                                                               

 

Refer to the Surgical Assistance Fees Billing Tips

 

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