North Carolina Health Insurance Plans | Blue Cross NC



OVERVIEW: Blue Cross and Blue Shield of North Carolina (BCBSNC) developed a new reimbursement policy for assistant surgeons, physician assistants, nurse practitioners and nurse midwives. The change in policy brings BCBSNC’s reimbursement more in line with that of the Centers for Medicare & Medicaid Services (CMS) and industry standards. Under the new policy, for dates of service on or after October 1, 2015, the assistant surgeon benefit for a covered procedure is 16% of the maximum allowed for the procedure. The physician assistant, nurse practitioner and nurse midwife benefit for a covered procedure is 13.6% of the maximum allowed for the procedure.

The following questions and answers have been compiled to assist with inquiries that may arise in regards to the change in BCBSNC’s reimbursement policy.

| Assistant Surgeons, Physician Assistants, Nurse Practitioners and Nurse Midwives |

Why is BCBSNC revising their reimbursement policy for assistant surgeons, physician assistants, nurse practitioners and nurse midwives?

BCBSNC continues our efforts to offer affordable health care in North Carolina. We have revised our policy to better bring BCBSNC’s reimbursement in line with that of the Centers for Medicare & Medicaid Services (CMS) and industry standards.

Where can additional information be obtained regarding BCBSNC policies and claim filing guidelines for assistant surgeons, physician assistants, nurse practitioners and nurse midwives?

BCBSNC’s Corporate Medical Policy; Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines and the BlueBookSM Provider eManual are resources that offer additional information regarding BCBSNC’s policies and claim filing guidelines. The BlueBookSM Provider eManual is currently being updated to reflect the policy change.

Is the reimbursement policy change applicable to all BCBSNC lines of business?

The reimbursement policy change does not impact BCBSNC Medicare Advantage plans (Blue Medicare HMOSM and Blue Medicare PPOSM) and the Federal Employee Program.

| Assistant Surgeons |

What is BCBSNC’s definition of an assistant surgeon?

An assistant surgeon is defined as a physician who actively assists the operating surgeon. An assistant may be necessary because of the complex nature of the procedure(s) or the patient’s condition. The assistant surgeon is usually trained in the same specialty.

When are assistant surgeon benefits considered for reimbursement?

An assistant surgeon must be appropriately board-certified or otherwise highly qualified as a skilled surgeon, and licensed as a physician in the state where the services are provided. An assistant surgeon may be of the same specialty or subspecialty, or may be of a different specialty. On occasion, a procedure for which assistant surgeon benefits are not allowed may be unusually complex for a particular patient and warrant assistant surgeon services. These cases will be reviewed on an individual consideration basis.

What is BCBSNC’s reimbursement policy for services performed by an assistant surgeon?

Services performed by the primary surgeon will be allowed at 100% of the maximum allowance for the primary procedure performed. An additional 16% will be allowed to the assistant surgeon if criteria for assistant surgeon services are met. Claims for more than one surgeon should have each surgeon’s provider identification number. Providers should always refer to multiple surgical procedure and bundling guidelines for procedures performed in addition to the primary procedure(s) during the same operative session.

What modifiers do BCBSNC recognize for surgical assistant services?

Surgical assistant services may be identified by adding modifier -80 to the usual procedure number(s). Minimum surgical assistant services are identified by adding modifier -81 to the usual procedure number. Modifier -82 may be used when a qualified resident surgeon is not available. Modifiers -62 and -66 designate services performed by two surgeons or a surgical team, and will be reviewed on an individual consideration basis. Both, modifiers – 62 and -66, will be denied when a claim for the same procedure code without the modifier has been previously submitted and processed for a different provider. Providers should remember that inclusion of a code in a BCBSNC policy does not guarantee it will be reimbursed.

Does BCBSNC require documentation for services performed by an assistant surgeon?

BCBSNC may request documentation to support the need for an assistant surgeon. Additionally, BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

| Physician Assistants, Nurse Practitioners and Nurse Midwives |

What are BCBSNC’s requirements for a physician assistant, nurse practitioner, and nurse midwife that perform services for BCBSNC members?

A physician assistant, nurse practitioner and/or nurse midwife performing services for BCBSNC members must be appropriately certified or licensed in the state where the services are provided, and be credentialed in the facility where the procedure is performed.

When are physician assistants, nurse practitioners and nurse midwives benefits considered for reimbursement?

Benefits are allowed when medical necessity and appropriateness of assistant surgeon services are met, and when the physician assistant, nurse practitioner and nurse midwife is under the direct supervision of a physician. Separate benefits will not be allowed for a hospital-employed physician assistant, nurse practitioner and nurse midwife.

What is BCBSNC’s reimbursement policy for services performed by a physician assistant, nurse practitioner, or nurse midwife?

The physician assistant, nurse practitioner, and nurse midwife benefit for a covered procedure is 13.6% of the maximum allowed for the procedure. Providers should always refer to BCBSNC’s multiple surgical procedure and bundling guidelines for procedures performed in addition to the primary procedure(s) during the same operative session.

What modifiers do BCBSNC recognize when services are performed by a physician assistant, nurse practitioner and nurse midwife?

The modifier -AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. BCBSNC uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed.

Does BCBSNC require documentation for services performed by a physician assistant, nurse practitioner and nurse midwife?

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

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FAQs

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Assistant Surgeon, Physician Assistant, Nurse Practitioner and Nurse Midwife

Reimbursement Policy Change Effective October 1, 2015

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