Medicare covers PAs for first assisting at surgery at 85 percent of the physician fee schedule or 13.6 percent of the primary surgeon's fee for the surgery (85 percent of the physician first assistant rate, 16 percent). PAs can provide the same range of first assistant services as physicians. A claim for first assisting at surgery should be submitted with the PA's NPI number (or PIN) and the "AS" modifier appended to the surgical code.
PAs should be aware of the Medicare list of approximately 1,900 CPT codes for which a first assistant at surgery will not be reimbursed. These code restrictions apply to all providers covered for first assisting at surgery under Medicare. The list was extracted from CMS's 2010 Physician Fee Schedule Relative Value File, which may be examined directly by following the Physician Fee Schedule 2010 instructions.
PAs First Assisting in Teaching Hospitals
Medicare restricts coverage for PAs (or physicians) who first assist in a teaching hospital that has a graduate education program in the fields of medicine, osteopathy, dentistry, or podiatry and is approved by the appropriate accrediting body for graduate education. In general, no reimbursement payment is made for first assisting at surgery when it is provided in a teaching hospital that has a training program related to the medical specialty required for the particular surgical procedure and has a qualified resident available to perform the ser¬vice. Hospitals that only participate in the approved programs of other hospitals, or that have non-approved programs are not subject to these restrictions.
However, if these teaching hospitals have no "qualified" resident available, in trauma cases, or if the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative care of his or her patients, Medicare will cover the services of a PA first assistant. The exact criteria that determine a "qualified" resident are somewhat vague. Some Medicare carriers have said that the primary surgeon can make that judgment. The surgeon may believe that an available resident who has been on duty for an extended period of time may not be the best pair of hands to use in a particular operation. However, to use a PA or a physician for the first-assist duties because a quali¬fied resident is making rounds in another part of the hospital, for example, would probably not be appropriate.
The Medicare carrier may require that the first-assist claim be accompanied by a certificate that reads as follows:
"I understand that section 1842(b)(6)(D) of the Social Security Act generally prohibits Medicare Part B...payment for services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services for which payment is claimed were medically necessary, and that no qualified resident was available to perform the services. I further understand that these services are subject to post-payment review by the Medicare carrier."
Check with your local Medicare carrier regarding this requirement.
