tci General Surgery Coding Alert - 2005 Issue 4

Reader Questions: Co-Surgery Status Depends on Documentation

Question: Our surgeon performed the bilateral pelvic lymph node dissection and omentectomy during a total abdominal hysterectomy. Should we bill his portion as an assistant surgeon or a co-surgeon? Or, should we report the lymph node excision separately?Pennsylvania Subscriber Answer: Proper coding in this case depends both on the general surgeon's level of involvement and on the documentation he provides.To qualify as co-surgeons, two surgeons must perform "distinct components" of a single identifiable CPT procedure, according to AMA guidelines. Your description indicates that your surgeon and the other surgeon did perform distinct components of the surgery during...

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