TRICARE Manuals - Display Chap 1 Sect 17 (Change 66, Jan 6, 2023)

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)

Revision: C-48, April 17, 2020

1.0 CPT PROCEDURE 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.

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