1 Retired: 3/31/2019 Effective Date: 10/01/2015 Reimbursement Clinical Guidelines: Assistant Surgeon Reimbursement Policy Position This reimbursement policy applies to FirstCare Health Plans’ Commercial (HMO, PPO, SF) assistant surgeons. Assures assistant surgeon claims reimburse appropriately according to medical necessity guidelines and the member’s health benefit plan. Marketplace (ACA) and Medicare health plans follow Centers for Medicare & Medicaid (CMS) guidelines. All Firstcare health plans follow the MCG Assistant Surgeon Guidelines 22nd Edition: The tables (below) replicate the Assistant Surgeon Guidelines information include in the Inpatient and Surgical Care guidelines, 22nd edition. Service codes that are not not included are not reimbursable. Surgical assistant services are idenitifed by adding one of the following modifiers: AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant 80 Assistant Surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon (when qualified resident surgeon not available) Disclaimer FirstCare has developed coding and reimbursement policies (“Reimbursement Policies”) to provide ready access and general guidance on payment methodologies for medical, surgical and behavioral health services. These policies are subject to all terms of the Provider Service Agreement as well as changes, updates and other requirements of Reimbursement Policies. All Reimbursement Policies are also subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10), FirstCare accepts codes valid for the date of service. Additionally, Reimbursement Policies supplement certain standard FirstCare benefit plans and aid in administering benefits. Thus, federal and state law, contract language, etc. take precedence over the Reimbursement Policies (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Coverage Determinations [LCDs] or other published documents). Moreover, the terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from Reimbursement Policies. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in Reimbursement Policies. Most importantly, our Reimbursement Policies relate exclusively to the administration of health benefit plans and are not recommendations for treatment or treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. All Reimbursement Policies are subject to change prior to the annual review date. Lines of business (LOB) are subject to change without notice; individual Reimbursement Policies list the applicable LOBs. Applicable Billing Codes Assistant Surgeon Reimbursable Service Codes CPT Description 0054T Computer‐assisted musculoskeletal surgical navigational orthopedic procedure, with image‐guidance based on fluoroscopic images (List separately in addition to code for primary procedure) 12940 N Hwy 183 Austin, Texas 78750 | 512.257.6000 | FirstCare.com 2 Assistant Surgeon Reimbursable Service Codes CPT Description 0055T Computer‐assisted musculoskeletal surgical navigational orthopedic procedure, with image‐guidance based on CT/MRI images (List separately in addition to code for primary procedure) 0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) 0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure) 0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) 0184T Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, full thickness) 0195T Arthrodesis, pre‐sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5‐S1 interspace 0196T Arthrodesis, pre‐sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4‐L5 interspace (List separately in addition to code for primary procedure) 0202T Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar 0312T Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming 0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator 0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator 0335T Extra‐osseous subtalar joint implant for talotarsal stabilization 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0396T Intra‐operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure) 0420T Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas 0437T Implantation of non‐biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure) 0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano‐electrical skin interface and subcutaneous electrodes) 12940 N Hwy 183 Austin, Texas 78750 | 512.257.6000 | FirstCare.com 3 Assistant Surgeon Reimbursable Service Codes CPT Description 0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal 0453T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano‐electrical skin interface 0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode 0455T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano‐electrical skin interface and electrodes) 0456T Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal 0457T Removal of permanently implantable aortic counterpulsation ventricular assist system; mechano‐electrical skin interface 0458T Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode 0459T Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano‐ electrical skin interface and electrodes 0460T Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode 0461T Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device 0483T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed 0484T Transcatheter mitral valve