Physicians as Assistants at Surgery: 2020 Update Participating Organizations: American College of Surgeons American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of Otolaryngology – Head and Neck Surgery American Association of Neurological Surgeons American Pediatric Surgical Association American Society of Colon and Rectal Surgeons American Society of Plastic Surgeons American Society of Transplant Surgeons American Urological Association Congress of Neurological Surgeons Society for Surgical Oncology Society for Vascular Surgery Society of American Gastrointestinal Endoscopic Surgeons The American College of Obstetricians and Gynecologists The Society of Thoracic Surgeons Physicians as Assistants at Surgery: 2020 Update INTRODUCTION This is the ninth edition of Physicians as Assistants at Surgery, a study first undertaken in 1994 by the American College of Surgeons and other surgical specialty organizations. The study reviews all procedures listed in the “Surgery” section of the 2020 American Medical Association’s Current Procedural Terminology (CPT TM). Each organization was asked to review new or revised codes since 2018 and determine whether the operation requires the use of a physician as an assistant at surgery: (1) almost always; (2) almost never; or (3) some of the time. The results of this study are presented in the accompanying report, which is in a table format. This table presents information about the need for a physician as an assistant at surgery. Also, please note that an indication that a physician would “almost never” be needed to assist at surgery for some procedures does NOT imply that a physician is never needed. The decision to request that a physician assist at surgery remains the responsibility of the primary surgeon and, when necessary, should be a payable service. It should be noted that unlisted procedure codes are not included in this table because by nature they are undefined and vary on a case-by-case basis. The organizations participating in this effort understand that local resources and patient characteristics can have an impact on the type of professional who may be asked to serve as an assistant at surgery. In fact, the College often receives requests for an assessment of how and when non-physician providers may serve in this role and for what procedures. This is an enormously complex issue that cannot be addressed by a single table of the sort included in this report. However, the inclusion of any particular service on this table should not be interpreted to mean that a non-physician provider can never serve as an assistant at surgery in some circumstances, nor should the omission of a service on this list be interpreted to mean that assistance from non-physician providers is not needed. An excerpt from the American College of Surgeons Statements on Principles has been included in this document in an effort to address the issue of non-physician assistants, at least in part. The excerpt “Surgical Assistants” describes the College’s view on the qualifications of those who serve as first assistants in the operating room. Questions concerning this study or requests for additional copies should be directed to the College as follows: American College of Surgeons 20 F Street, NW, Suite 1000 Washington, DC 20001 Tel 202/337-2701 Fax 202/337-4271 e-mail: [email protected] American College of Surgeons Statements on Principles II. QUALIFICATIONS OF THE RESPONSIBLE SURGEON G. Surgical Assistants The first assistant in a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions. The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility. The American College of Surgeons supports the concept that, ideally, the first assistant at the operating table should be a qualified surgeon or a resident in an approved surgical training program. Residents who have appropriate levels of training should be provided with opportunities to assist and participate in operations. If such assistants are unavailable, other physicians who are experienced in assisting may participate. It may be necessary to have nonphysicians serve as first assistants. Surgeon assistants (SAs) or physician assistants (PAs) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a SA or PA should include the following qualifications and credentials: • Specification of which surgeon the applicant will assist and what duties that will be performed. • Indication of which surgeon will be responsible for the supervision and performance of the SA or PA. • Review and approval of the application by the hospital board. • Registered nurses with specialized training may function as first assistants. If such a situation should occur, the size of the operating room team should not be reduced; the nurse assistant should not simultaneously function as the scrub nurse and instrument nurse when serving as the first assistant. Nurse assistant practice privileges should be granted based upon the hospital board's review and approval of credentials. Registered nurses who act as first assistants must not have responsibility beyond the level defined in their state nursing practice act. Surgeons are encouraged to participate in the training of allied health personnel. Such individuals perform their duties under the supervision of the surgeon. 1 2020 Assistant at Surgery Consensus Almost Some- Almost CPT 2020 Descriptor Always times Never2 Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List 10004 X separately in addition to code for primary procedure) 10005 Fine needle aspiration biopsy, including ultrasound guidance; first lesion X Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion 10006 X (List separately in addition to code for primary procedure) 10007 Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion X Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion 10008 X (List separately in addition to code for primary procedure) 10009 Fine needle aspiration biopsy, including CT guidance; first lesion X Fine needle aspiration biopsy, including CT guidance; each additional lesion (List 10010 X separately in addition to code for primary procedure) 10021 Fine needle aspiration biopsy, without imaging guidance; first lesion X Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, 10030 X lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, 10035 X radioactive seeds), percutaneous, including imaging guidance; first lesion Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, 10036 radioactive seeds), percutaneous, including imaging guidance; each additional lesion X (List separately in addition to code for primary procedure) Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, 10040 X cysts, pustules) Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or 10060 X subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or 10061 X subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple 10080 Incision and drainage of pilonidal cyst; simple X 10081 Incision and drainage of pilonidal cyst; complicated X 10120 Incision and removal of foreign body, subcutaneous tissues; simple X 10121 Incision and removal of foreign body, subcutaneous tissues; complicated X 10140 Incision and drainage of hematoma, seroma or fluid collection X 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst X 10180 Incision and drainage, complex, postoperative wound infection X 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface X Debridement of extensive eczematous or infected skin; each additional 10% of the body 11001 X surface, or part thereof (List separately in addition to code for primary procedure) Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue 11004 X infection; external genitalia and perineum Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue 11005 X infection; abdominal wall, with or without fascial closure Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue 11006 infection; external genitalia, perineum and abdominal wall, with or without fascial X closure Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or 11008 recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition X to code for primary procedure) Debridement including removal of foreign material at the site of an open fracture and/or 11010 X an open dislocation (eg, excisional debridement); skin and subcutaneous tissues 1 This table presents information about the need for a physician as a first assistant at surgery