- When a surgical procedure(s) is performed on a patient, the individual billings by the anesthetist, assistant and surgeon effect the payment for each physician. To avoid delay in processing, it is recommended that all parties confer with the surgeon and bill the applicable fee items.
- When assisting at a surgery, the calculation for the surgical surcharge fees (e.g. 01210 - evening (1800hrs. to 2300hrs.) - 37.78%, 01211- night (2300hrs. to 0800hrs.) - 60.57%, 01212 - Saturday, Sunday or Statutory holiday (0800hrs. to 2300hrs.) - 37.78% are based on the assist fee paid and not the surgery.
- Assist and visit fees are not paid together on the same date of service unless medically required and distinct unrelated times are provided.
- When billing assist fees that are time based (e.g. fee item 00198), the start and end time of the surgery must be provided in the time field on the claim submission. If the times are not provided, the claim will be refused with explanatory codes YY and CF.
YY (Pre-edit system refusal. See secondary explanatory code(s).)
CF (Time called or time service was rendered is missing or invalid.)
- When billing fee item 70019 (Certified Surgical Assistant) for a surgery that is not “C” prefixed. An explanation outlining the unusual technical difficulty unique to the patient must be submitted by the operating surgeon and independent consideration will be given to each case. If the required information is not received, or the information provided does not meet the criteria for fee item 70019, the appropriate general surgical assistant fees (e.g. fee item 00196) would be paid with explanatory codes QS or ED and QJ.
QS (70019/70020 requires confirmation of medical necessity from surgeon.)
QJ (Adjusted to agree with the surgical/assist fee item paid for this date of service.)
ED (There is insufficient medical necessity to process this claim.)
Refer to the Specialist Hospital Visits Information