Modifier 80

Modifier 80 (2022) Description, Uses, Guidelines & Examples

Modifier 80 appends for the service when another physician assists at surgery as an “Assistant surgeon.”

Summary

Modifier 80 is applicable when surgical assistant services need to report on the claim. The assistant at the surgery requires modifiers and payment indicators for reimbursement.

An assistant at surgery is the provider who assists the principal physician during the procedure or surgery session on the same patient. A physician, clinical nurse specialist, physician, or nurse practitioner is allowed or authorized to work as an assistant at surgery and dynamically participate during the procedure. 

Modifier 80 is inappropriate to bill with non-physician practitioners. Medicare does not consider physician assistant (PA), advanced registered nurse practitioner (ARNP), and clinical nurse specialist (CNS) and also does not consider first assistant (RNFA) as a qualified Medicare provider.

The following is the list of modifiers applicable when reporting assistant services for a surgical procedure:

Modifier 80 is applicable with the assistant surgeon to report to physician’s services only. It adds to the claim to identify the assistant services by adding 80 to the usual procedure code. It also indicates that an assistant surgeon actively participates and provides complete assistance to the primary surgeon. It does not apply to non-physician practitioners. 

Modifier 81 is applicable with the assistant surgeon to report to physician’s services only. It is mainly used with commercial payors and does not frequently use for Medicare claims. Still, they provide Minimal surgical assistance compared to 80 on the claim to identify the assistant services by adding 81 to the usual procedure code.

Modifier AS is applicable instead of 80 when the Non-Physician provider, such as a PA, ARNP, or CNS, provides the assistant services during the procedure. 

Modifier 82 is applicable instead of 80 when a qualified resident surgeon is not present at the teaching facility and only reports to the physician services. The service must perform in the teaching facility and use this modifier as a prerequisite due to the unavailability of a qualified resident surgeon.

Documentation must support the circumstances that a resident surgeon was not available and inappropriate to use with the non-physician provider.

80 modifier

Modifier 80 Description

Modifier 80 appends for the service when another physician assists at surgery as an “Assistant surgeon.”

What Is Modifier 80?

Modifier 80 indicates the assistant at the surgery who is also a Physician. The assistant provides support and assistance to the primary surgeon. Modifier 80 is inappropriate to use with non-physician assistants at surgery, such as Physician assistants or Nurse practitioners (NP). 

When To Use Modifier 80

The following are the use of modifier 80 when appended with the service:

80 applies to the service when another Physician assists in the surgery as an assistant surgeon.

Modifier 80 signifies the associate services provided by MD  at the surgery.

According to the physician fee schedule for surgical payment, Medicare allows 16% of the total.

Modifier 80 Guidelines

Modifier 80 is applicable when An “assistant at surgery a physician or non-physician practitioner (NPP) actively participates during surgical procedure or service. Assistant services are more extensive than usual ancillary services.

Both surgeons should agree on the procedure and documentation. Documentation must establish the medical necessity and appropriateness of modifier 80 with CPT codes. Otherwise, 80 cannot bill to the insurance or third-party payors.

The global surgery rule does not apply to assistant services such as physician or non-physician practitioners (NPP).

Modifier 80 applies to the surgical procedure when MD or DO performs the assistant services during the surgery.

80 is inappropriate to use with minimum surgical assistant services and applies with surgical procedure codes. 

Modifier 80 is inappropriate to use with the assistant at the surgery when provided by MD or DO, but a qualified resident available is unavailable.

Modified 80 is inapplicable to use with an assistant at surgery services provided by a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS). Medicare may allow 85 % of the 16% for PA, NP, or CNS. 

80 is inappropriate to use on the same claim line with modifier AS, and insurance may deny this claim as unprocessable. The rendering provider must be NPP instead of the MD or DO for

Modifier 80 is inappropriate to report when the surgeon involves other members of the same group practice in the post-operative care, including MD/DO or NPP assistant surgeon. It allows Medicare to pay the global fee schedule amount for surgery CPT code.

The following are the payments indicator according to the physician fee schedule for assistants at surgery:

If modifier 80 bills with 0 payment indicator, it may apply Payment restrictions for assistants at the surgery unless documentation submits to insurance to support the medical necessity.

If 80 bills with one payment indicator, it may apply a Statutory payment restriction for assistants at the surgery. The insurance may not pay for surgical assistant service.

If modifier 80 bills with two payment indicators, it may not apply payment restriction for assistants at the surgery. The insurance may pay for surgical assistant service.

Modifierifer 80 and AS are inappropriate to bill on the same claim line; it may deny by the insurance as unprocessable.

Modifier 80 Examples

The Following the examples of when modifier 80 appends with the CPT codes:

Example 1

A 39-year-old male with tumors on the lumbar region presented to the emergency department with c/o constant low back pain that started four days ago. The patient was unable to walk for 1-week. 

The patient is consulted with his primary care physician and suggested to go emergency department. Denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms. 

The patient took his routine medication. The physician ordered a CT scan of the lumbar region and laboratory studies to confirm if the tumor metastasized or not. The physician decides to do a surgical procedure to excise cancer. The service performs successfully. 

The physician assists the primary surgeon in the tumor removal of the lumbar region and actively participates in the entire surgery. The physician who helps and the primary physician may bill for the lumbar tumor excision separately, with modifier 80 on the claim.

Suppose the NPP assists the primary surgeon in the tumor removal of the lumbar region and actively participates in the entire surgery. In that case, it is appropriate to report with modifier AS instead of 80.

Example 2

A 76-year-old male presents to the office for radiculopathy and stenosis of the lumbar region. Denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms.

A patient has had severe low back pain since last week. The patient took some medication for pain, but it is getting worse daily. 

CT scans of the lumbar region revealed spondylosis of the L2-L3 level, disc protrusion at the L4-L5 level, and degenerated changes at the L5-S1 area. The patient requested the physician for pain management as he could not bear it. 

The primary physician performs surgery at L5-S1 to decompress the nerves, which the physician-assisted and actively participates in the lumbectomy procedure—the physician who assists and principal surgeon bills lobectomy procedure with modifier 80.

If the NPP assists the primary surgeon in the lumbectomy procedure and actively participates in the entire surgery, it is appropriate to report with modifier AS instead of 80.

Example 3 

A 39-year-old male with PMH of thyroid cancer presents to the emergency department with c/o constant neck pain that started four days ago. The patient was unable to eat anything for 1-week.  

The patient is consulted with his primary care physician and suggested to go emergency department. Denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms.

The patient took his routine medication. The physician ordered a CT scan of the neck’s soft tissues and laboratory studies to see if the cancer was back. The physician who assist and principal bill neck tumor excision with modifier 80. The physician then performs tumor excision on the channel with NPP assistance.

If the NPP assists the primary surgeon in the neck tumor excision and actively participates in the entire surgery, it is appropriate to report with modifier AS instead of modifier 80.

Modifier 80 Reimbursement

Medicare reimburses the service of an assistant at the surgery. If the physician performs the surgery as an assistant, they may pay 16% of the total amount according to the physician fee schedule. In contrast, If NPP performs the surgery as an assistant, they may pay 85% of the 16% of the total amount according to the physician fee schedule.

The NPP requires modifier AS instead of modifier 80 for reimbursement. Otherwise, insurance or third-party payors may deny the procedure of assistance. 

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