Skip to main content

Military Health System

Utility Navigation Links

Need larger text?
TRICARE Reimbursement Manual 6010.64-M, April 2021
General
Chapter 1
Section 17
Assistant Surgeons
Issue Date:  April 5, 1989
Authority:  32 CFR 199.2(b) and 32 CFR 199.4(c)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT CODES
10040 - 69990, 92982, 92984, 92995, 92996, 92998
2.0  APPLICABILITY
This policy is mandatory for reimbursement of services provided by either network or non-network providers. However, alternative network reimbursement methodologies are permitted when approved by the Defense Health Agency (DHA) and specifically included in the network provider agreement.
3.0  ISSUE
How are assistant surgeons to be reimbursed?
4.0  BACKGROUND
An assistant surgeon is a physician, dentist, podiatrist, certified physician assistant, nurse practitioner, or certified nurse midwife acting within the scope of their license, who actively assists the operating surgeon in the performance of a covered surgical service. Refer to Section 6 for information regarding reimbursement of certified physician assistants and nurse practitioners performing as assistant surgeons.
5.0  POLICY
5.1  Services of an assistant surgeon are payable when:
5.1.1  The surgical procedure is of such complexity and seriousness as to warrant an assistant surgeon. The assistant surgeon’s services must be of the type that cannot be accomplished by operating room nurses or other such operating room personnel.
5.1.2  Interns, residents or other house staff are not available to provide the surgical assistance services in the specialty area required. This necessarily entails that the assistant be involved in the actual performance of the procedure, not simply in other, ancillary services. Since an assistant would, thus, be occupied during the surgical procedure, the assistant would not be available to perform (and thus, could not bill for) another surgical procedure during the same time period.
Note:  Standby assistant surgeon services are not reimbursed when the assistant surgeon does not actively participate in the surgery.
5.2  The allowable charge for an assistant surgeon (where such services are covered) is to be the lower of the billed charge or 16% of the prevailing charge for the surgery involved. When an assistant surgeon is involved in multiple surgery, the same procedures used for determining reimbursement for the primary surgeon shall be used in determining reimbursement for the assistant surgeon.
5.3  No payment may be made for an assistant surgeon when co-surgeons are reimbursed, see Section 16.
5.4  No payment shall be made for the services of an assistant surgeon who is not an otherwise authorized TRICARE provider. See TRICARE Policy Manual (TPM), Chapter 11.
5.5  No payment shall be made for the services of a surgical assistant not meeting the requirements of this section.
6.0  EFFECTIVE DATE
The 16% reimbursement methodology is effective for assistant surgeon services provided on or after November 1, 1993.
- END -
You are leaving Health.mil The appearance of hyperlinks does not constitute endorsement by the Defense Health Agency of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website. You are leaving Health.mil View the external links disclaimer.
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery