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Simple MSP Billing for SA

Claim Manager SA is simple MSP billing software for surgical assistants who want to do their billing themselves.

General practitioners performing surgical assistance

1. Select surgical assist code

  • 00195/6/7/8 – General assists
  • 00193 – Open heart surgery

2. Add 1st assist of the day

  • 13194 – 1st surgical assist of the day

3. Add out-of-office hours premiums

  • 01200/1/2 – Call-out charges
  • 01210/1/2 – Continuing care surcharges

1. Select Surgical Assistance Billing Code(s).

Surgical assist billing code depends on the total operative fee(s) for procedure(s) billed by the surgeon, except assisting at open-heart surgery.

For the first THREE hours or fraction thereof, bill ONE of the following codes for EACH eligible procedure during one assist.

If the total operative fee(s) for procedure is less than than $317.00 inclusive, bill
  • 00195 – $131.64
Example: Surgical fee(s) paid to the surgeon:  fee item V07475 (partial Axillary dissection)  – $232.77. Code billable for surgical assistance – fee item 00195.
If the total operative fee(s) for procedure ranges from $317.01 to 529.00 inclusive, bill
  • 00196 – $185.59
Example: Surgical fee(s) paid to the surgeon:  Fee item V07472 (total Mastectomy) –  $465.01. Code billable for surgical assistance – fee item 00196.
If the total operative fee(s) for procedure is over $529.00, bill
  • 00197 – $245.47
Example 1: Surgical fee(s) paid to the surgeon:
  • Fee items V07472 (100%-$465.01) and
  • V07475 (50%-$116.39).
The total of the two surgical fees equal $581.40. Code billable for surgical assistance – fee item 00197. Example 2: Fee item 03161 (posterior laminectomy for localized spinal stenosis, two levels or less – $773.94) is performed.  The surgical assistant time is from 0800 to 1100. Only 1 x fee item 00197 is payable.

After THREE hours of continuous surgical assistance for one patient, add code 00198.

00198 –  Time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof $27.80.
Fee item 03161 (posterior laminectomy for localized spinal stenosis, two levels or less -$773.94) is performed. The surgical assistant time is from 0800 to 1135 hrs., payment would be:
  • From 0800 to 1100, 1 x fee item 00197 (surgical assistance at surgery/surgeries over $529.00).
  • From 1100 to 1135, 3 x fee item 00198 (time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof).

If assisting at OPEN-HEART surgery, do not bill 00195, 00196, 00197 or 00198. Bill code 00193.

For non-CVT-certified surgical assistance at open-heart surgery bill
  • 00193 – $28.39 per quarter hour or major portion thereof
Note: The same fee applies equally to all assistants (first, second, etc.). Example. Fee item 07853 (mitral valve, commissurotomy – $1,394.63) is performed. The surgical assistant time is from 0800 to 1200 hrs (4 hours total). Payment would be: 16 x fee item 00193 (non-CVT-certified surgical assistance at open-heart surgery, per quarter hour or major portion thereof). Sixteen units is calculated as 4 hours divided by 15 minutes. Quiz. A multiple valve replacement (fee item 07864 at $2,348.92) is performed and only 1 assist is required in this case, the surgical assistant time is from 0800 to 1215 hrs.. Which of the following is the applicable billing? (a) For a specially qualified assistant: 1 x fee items 07917 (first assistant for operations over $1033.00) and 1 x fee item 07920 (time, after 4 hours of continuous surgical assistance for one patient, each 15 minute period or fraction thereof). For a non-CVT certified surgical assist: 17 x fee item 00193 (Non-CVT-certified surgical assistance at open-heart surgery, per quarter hour or major portion thereof) (b) 1 x fee item 70019 (Certified Surgical Assistant), 8 x fee item 70020 (time after one hour of continuous certified assistance for one patient) and 5 x fee item 00198 (time, after 3 hours of continuous surgical assistance for one patient, each 15 minutes or fraction thereof) (c) 1 x fee item 00845 (cardiologist assist for first hour or fraction thereof) and 13 x fee item 00846 (after one hour, for each 15 minutes or fraction thereof) The correct answer is (a). General practitioner would bill code 00193, while certified surgical assistant would bill codes 07917 and 07920 for open heart surgery.

When to bill for surgical assists

Fee items 00195, 00196 and 00197 are billable by all specialties that have the qualifications to assist at surgical procedures. Payment is based on the value of the total operative fee(s) that is paid to the operating surgeon.
In those rare situations where an assistant is required for minor surgery a detailed explanation of need must accompany the account to the Plan.
Where a medical practitioner renders surgical assistance at two operations under the same anesthetic but for which repositioning or redraping of the patient or more than one separately draped surgical operating field is medically/surgically required, separate assistants’ fees may be claimed for each operation, except for bilateral procedures, procedures within the same body cavity, or procedures on the same limb. –  MSC Payment Schedule Index, D. 5.4. (ii). Example 1. The operations performed are:
  • Fee item V70479 (radical mastectomy) $762.62
  • Fee item 06018 (removal of tumour, including intraoral – more than 10 cm) $443.84.
*Information provided is that fee item 06018 is performed on the back and the tumour size is 12 cm*. In accordance with Preamble D. 5. 3. ii., fee items V70479 at 100% ($762.62) and 06018 at 75% ($332.88) are payable to the surgeon. If assistance is required at both procedures,
  • 1 x fee item 00197 is payable for the procedure on the breast and
  • 1 x fee item 00196 is payable for the procedure on the back, as the second procedure would require a separate incision , repositioning and re-draping.
Example 2. The operations performed are bilateral mastectomies:
  • Fee item 2 x V07472 (total, for malignancy) $465.01
  • In accordance with Preamble D. 5. 3. i., 2 x fee item V07472 is payable at 150% ($697.52) to the surgeon.
Only 1 x fee item 00197 is payable to the surgical assistant as this is a bilateral procedure. Example 3. The operations performed are:
  • Fee item V07636 (resection of small intestine) $591.73
  • Fee item V07627 (gastrojejunostomy) $425.82.
  • In accordance with Preamble D. 5. 3. i., fee items V07636 at 100% ($591.73) and 07627 at 50% ($292.91) are payable to the surgeon.
Only 1 x fee item 00197 is payable as the procedures performed are in the same body cavity. Example 4. The operations performed are on the left arm:
  • Fee item 52735 (O.R.I.F – two parts of the proximal humerus) – $531.06.
  • Fee item 53765 (O.R.I.F. of the radius and ulna shaft) – $531.06.
  • In accordance with Preamble D. 6. a., fee items 52735 and 53765 are both payable at 100% to the surgeon.
Only 1 x fee item 00197 is payable as the surgery is performed on the same limb. Quiz. A mastectomy (1 x fee item V07498 at 100% – $555.74) and an anoplasty (1 x fee item V70665 at 75% – $332.10) are performed. Which of the following is the applicable billing? (a) 2 x fee item 00197 (assistance at surgery over $529.00) (b) 2 x fee item 00196 (assistance at surgery $317.01 to 529.00 inclusive) (c) 1 x fee item 00197 (assistance at surgery over $529.00) for the mastectomy and 1 x fee item 00196 (assistance at surgery $317.01 to 529.00 inclusive) for the anoplasty as the second procedure is in a different body cavity and would require re-draping and a separate incision. The correct answer is (c). 1 x fee item 00197 (assistance at surgery over $529.00) for the mastectomy and 1 x fee item 00196 (assistance at surgery $317.01 to 529.00 inclusive) for the anoplasty as the second procedure is in a different body cavity and would require re-draping and a separate incision.
Where surgery is abandoned, independent consideration will be given to the fee applicable to the assistant, to a maximum of 50 percent of the listed assistant fee for the intended procedure. –  MSC Payment Schedule Index, D. 5.4. (v). Example: The patient was undergoing a hysterectomy operation (fee item 04228 at $569.80) and had a myocardial infarction necessitating resuscitation. The surgery was abandoned due to the patient’s poor health. A percentage of fee item 00197 would be paid based on the information provided. Hint: An operative report should be submitted to facilitate payment.
How to bill for abandoned surgery
To bill for an abandoned surgery, general practitioners need to use the code 00199 – miscellaneous fee item for general practice. Enter 1 service unit and the amount of up to 50% of the surgical assist fee payable had the surgery gone through (eg. up to 50% of the fee items: 00195, 00196, 00197). Fax the operative report or the report about partial procedure to MSP to fax # 250-405-3591. Add a note into your claim explaining the situation and confirming that the report was sent.

When to bill patient directly

If you assisted at the procedure whose billing code starts with letter “S”, a surgical assistant fee is not payable for that procedure. –  MSC Payment Schedule Index, B. Prefixes to fee codes. Quiz. A percutaneous nephrostomy (fee item S00978 at $288.93) is performed. Which of the following is the applicable billing? (a) Fee item 00195 (assistance at surgery less than $317.00 inclusive) (b) Fee item 00845 (cardiologist assist for first hour or fraction thereof) (c) Assist fees are not payable as the procedure is prefixed with the letter “S” The correct answer is C. In accordance with Preamble B., Prefixes to Fee Codes, Assist fees are not payable as the procedure is prefixed with the letter “S”.
Services requested or required by a “third party” for other than medical requirements are not insured under MSP. Services such as consultations, laboratory investigations, anesthesiology, surgical assistance, etc., rendered solely in association with other services which are not benefits also are not considered benefits under MSP, except in special circumstances as approved by the Medical Services Commission (e.g.: Dental Anesthesia Policy). – MSC Payment Schedule Index, C.1.
Authorization from MSP is required for those categories of procedures for alteration of appearance  for which some cases may not be a benefit under MSP policy. Where authorization has been denied or has not been obtained when required for a surgical procedure, the associated consultations, anesthesiology and surgical assistance also are not covered by MSP. Hospitalization costs also will remain the patient’s responsibility. – MSC Payment Schedule Index, D.9.1.
Medical Practitioner Services Excluded under the Inter-Provincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims: 1. Surgery for alteration of appearance (cosmetic surgery) 2. Gender-reassignment surgery 3. Surgery for reversal of sterilization 4. Routine periodic health examinations including routine eye examinations (including PAP tests for screening only) 5. In-vitro fertilization, artificial insemination 6. Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy 7. Services to persons covered by other agencies; Armed Forces, WorkSafe BC, Department of Veterans Affairs, Correctional Services of Canada (Federal Penitentiaries) 8. Services requested by a “Third Party” 9. Team conference(s) 10. Genetic screening and other genetic investigation, including DNA probes 11. Procedures still in the experimental/developmental phase 12. Anesthetic services and surgical assistant services associated with all of the foregoing. The services on this list may or may not be reimbursed by the home province. The patient should make enquires of that home province after direct payment to the BC medical practitioner. – MSC Payment Schedule Index, C. 11.
If MSP has not approved funding for the gender-reassignment surgery, any medical consultation(s), anesthesiology and surgical assistance services related to the surgery, will not be eligible for MSP funding. – MSC Payment Schedule Index, D.9.4.

How to calculate time of the surgical assist

Time, for the purposes of fee codes 00193, 00195, 00196, 00197, 00198, 07920, T70019 and T70020 is calculated at the earliest from the when the medical surgical assistant makes contact with the patient in the operating suite. The end time is defined as when the assistant leaves the operating suite. – MSC Payment Schedule Index, D. 5.4. (i).

When to bill visit fees on the day of surgical assistance.

Visit fees are not payable with surgical assistance listings on the same day, unless each service is performed at a distinct/separate time. In these instances, each claim must state time service was rendered.   Quiz. A physician was called to assist at an open reduction of the hip (fee item 55725 at $700.47) and arrived at the hospital at 1600hrs. Which of the following is the applicable billing? (a) Fee items 13200 (out of office visit, age 2-49) and 00197 (assistance at surgery over $529.00). (b) Fee item 00197 (assistance at surgery over $529.00) only. Visit fees are not payable in addition. (c) Fee item 00112 (emergency visit) and 00197 (assistance at surgery over $529.00). The correct answer is (b). Fee item 00197 (assistance at surgery over $529.00) only. Visit fees are not payable in addition.
If, in the interest of the patient, the referring medical practitioner is requested by the patient or the surgeon to attend but does not assist at the procedure, attendance at surgery may be claimed as a subsequent hospital visit. –  MSC Payment Schedule Index, D. 5.4. (iii).

If billing 14108 and 14109

If you bill 14108 and 14109, bill surgical assistant fees extra. 14108  – Post-natal care after elective caesarean section(1-14 days in-hospital) – $115.31 14109 – Primary management of labour and attendance at delivery and post-natal care associated with emergency caesarean section (1-14 days inhospital) – $466.87

If assisting with 78041 (Laser Lead Extraction)

Claims for surgical assistance for laser lead extraction are payable under 00197. 78041  – Laser Lead Extraction after 30 days, first lead – $1,382.72 9 Notes: i) Not payable with 07845, 33030, and 33057. ii) Includes any and all diagnostic imaging related to the surgery.

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2. Add First Surgical Assist of the Day Charge

If it was your first surgical assist of the day, add code 13194.

For the first surgical assist of the day, bill additional code
  • 13194 – $81.53
Notes: i) Restricted to General Practitioners ii) Maximum, of one per day per physician, payable in addition to 00195, 00196, 00197 or 00193.

3. Add Out-Of-Office Hours Premiums

The out-of-office premium is an additional fee that may be billed for services initiated and rendered within designated time limits. These premiums are applicable to eligible insured medical services provided to MSP beneficiaries and can be billed by both General Practitioners and Specialists. The out-of-office premiums include Call-Out charges and Continuing Care surcharges.

Add ONE code from EACH category, if applicable.

Bill in addition to  procedure ONE of the following, if applicable. Call-Out charges:
  • 01200  – Evening (call placed between 1800 hours and 2300 hours and service rendered between 1800 hours and 0800 hours) – $59.34;
  • 01201 – Night (call placed and service rendered between 2300 hours and 0800 hours)- $83.35;
  • 01202 – Saturday, Sunday or Statutory Holiday (call placed between 0800 hours and 2300 hours) – $59.34.
Bill in addition to surgical assistance code(s) ONE of the following, if applicable. – MSC Payment Schedule Index, Section 2(e). Continuing care charges:
  • 01210 – Evening (1800 hours to 2300 hours) – 37.78% of surgical (or assistant) fee
    • minimum charge $53.38
    • maximum charge $368.28
  • 01211 – Night (2300 hours to 0800 hours) –  60.57% of surgical (or assistant) fee
    • minimum charge – $74.98
    • maximum charge – $517.16
  • 01212 – Saturday, Sunday or Statutory Holiday (Service rendered between 0800 hours and 2300 hours.)  – 37.78% of surgical (or assistant) fee
    • minimum charge – $53.38
    • maximum charge – $368.28
Notes: i) Codes 01210, 01211 must have  a “start time” in the “start time” field of your submissions to be accepted by the system.

When to bill out-of-office hours premiums

Out-of-office premiums are not applicable to full or part-time emergency physicians, or physicians designated by a hospital emergency room as the on duty/on site physician. Those physicians are referred to the Emergency Medicine Section of the Payment Schedule.
The out-of-office hours premium listings apply only to those services initiated and rendered within the designated time limits. They apply to visits to a physician’s office only if the office is officially closed during the designated time period.

When to apply call-out charges

Call-out charges apply only when the physician is specially called to render emergency or non-elective services to a patient at a different geographical location during out-of-office hours and only when the physician must travel from one location to another to attend the patient(s). It is charged extra to the consultation or other visit, or extra to the procedure if no consultation or other visit charged.
The call must originate in the designated time frame and the service must be rendered in the designated time frame (i.e., 1800-0800 hours, weekends, and statutory holidays). Claims must state time service rendered. Codes 01200, 01201 must have a “start time” in the “start time” field of your submissions to be accepted by the system.
The call-out charge (fee item 01200, 01201, 01202) applies only to the first patient examined or treated on any one special visit (not day).  Additional patients seen during the same call-out may be eligible for the continuing care surcharges.
A call-out charge is applicable to each special call-out whether or not a previous call-out charge has been billed for the same patient on the same day. For example, a physician may provide a consultation during out-of-office hours for which a callout charge is applicable. The physician may then perform an operation on the same patient at a different time during out-of-office hours. If the physician was specially called, on separate occasions, to render both services and was required to travel from one location to another for both services, it would be appropriate to bill a call-out charge for the consultation and a call-out charge for the operation in addition to the regular fees for the services and any applicable continuing care operative and non-operative surcharges.
Fee item 01202 is not applicable for routine care provided on the weekend. This is a call-out fee, and all criteria in the Out-of-Office Hours Premiums section of the Payment Schedule must be met in order to bill this fee.

When to bill continuing care charges

Operative continuing care surcharges are applicable only to surgical procedure(s) requiring general, spinal, or epidural anaesthesia and/or requiring at least 45 minutes of surgical time. Quiz. Physician is called to suture a laceration at 1830 hours. Total time of the procedure is 10 minutes, and local anaesthesia is used. Is a surgical surcharge billable? (a) Yes (b) No The correct answer is (b). A surgical surcharge is only payable for surgical procedures requiring general, spinal, or epidural anaesthesia and/or requiring at least 45 minutes of surgical time.
When emergency surgery commences prior to 1800, even if the major portion of surgical time is after 1800, surgical surcharges are not applicable. If the surgery starts within time frame of one operative continuing care billing item and goes into the time frame of another billing,  the appropriate item for billing is determined by the period in which the major portion of the surgical time is spent. Quiz. Emergency laparoscopic cholecystectomy commences at 2250 hours and ends at 2350 hours. Which surgical surcharge is applicable? (a) Fee item 01210 (1800 hours to 2300 hours) (b) Fee item 01211 (2300 hours to 0800 hours) Correct answer is b. Timing for surgical surcharges is determined by the category in which the majority of time was spent. Although the surgery started prior to 2300 hours, the majority of surgical time was after 2300 hours. Therefore fee item 01211 applies. When billing, remember that start time must be 2300 hours, with the actual start time noted in your note record.
OPERATIVE continuing care surcharges are applicable only to emergency surgery or to elective surgery which, because of intervening emergency surgery, commences within the designated times.  For surgery that would normally be considered elective (e.g., sterilization) but that has been unexpectedly delayed by emergency surgery, ensure that your note record indicates, “bumped by emergency surgery” for correct payment of your claim. For surgical services bumped by emergency surgery, the surgery must commence within the designated times. Question 1. Laparoscopic sterilization booked for 1400 hours is bumped by emergency surgery. Surgery commences at 1750 hours and ends at 1820 hours. Which surgical surcharge is applicable? (a) No surgical surcharge is applicable. (b) Fee item 01210 (1800 hours to 2300 hours) The correct answer is (a). The surgery commenced prior to the designated time for surgical surcharge. Therefore, no surgical surcharge is applicable. Question 2. Laparoscopic sterilization booked for 1400 hours is bumped by emergency surgery. Surgery commences at 1810 hours and ends at 1840 hours. Which surgical surcharge is applicable? (a) No surgical surcharge is applicable. (b) Fee item 01210 (1800 hours to 2300 hours) The correct answer is (b). Surgical surcharges apply to elective surgery when bumped by emergency surgery and the surgery commences within the designated times.
When surgery is normally considered elective and is performed under the same anaesthetic as an emergency surgery, surgical surcharges apply to the entire surgical fee. Quiz. Abdominal (open) sterilization is performed under the same anaesthetic as an emergency Caesarian section. Surgery starts at 1840 hours and ends at 1940 hours. How does the surgical surcharge apply? (a) Fee item 01210 applies to the C-section only. (b) No surgical surcharge is applicable. (c) Fee item 01210 applies to both the C-section and the sterilization. The correct answer is (c). When an elective procedure is performed at the same time as an emergency procedure, the surgical surcharge applies to the combined fee.
To be billed in addition to surgical fees or surgical assistant fees for emergency surgical services provided outside regular office hours (i.e. 1800 – 0800 hours, weekends, and statutory holidays).
The following applies in the event that a consultation or visit is followed by surgery:
  1. the non-operative continuing care surcharge applies to the consultation or visit, and
  2. the operative continuing care surcharge applies to the surgery.

How to determine time for continuing care charges

When surgery commences within evening time period (1800 – 2300 hrs) and continues into night time period (2300 – 0800 hrs), the appropriate item for billing is determined by the period in which the major portion of the surgical time is spent.
If emergency surgery commences prior to 0800 and continues after 0800, surcharges are applicable to the entire surgical time.
Save time by skipping ``Referred by`` section
Surgical assistants do not need to fill in the “Referred by” section of the claim with the practitioner number of the surgeon. MSP finds the surgeon by the patient’s personal health number and the date of service in your claim.
Surgical Assistant's Check List - for General Physicians
1. How many operations were performed under the same anesthetic that qualify for independent billing of surgical assistant fees?
  • You might be able bill for multiple assists.
2. What is the billing code of the procedure(s)?
  • If a procedure starts with “S”, you will not be paid for the assist.
3. What are the total fees of each procedure payable to the surgeon, taking into consideration multiple fees and discounts for additional fees?
  • Your billing code depends on it.
4. Was it a minor procedure? Ask the surgeon to submit a note justifying your assistance at the minor procedure. Otherwise, you will not be paid. 5. What was the earliest time when you made a contact with the patient in the operating suite?
  • That was the start of your assistance. Your continuing care charge and charge for the assistance over three hours depend on it. You must report the start time on your claims.
6. When did you leave the operating suite?
  • Your might be eligible to bill a higher rated continuing care charge code if the major part of the procedure went past 11 pm. In addition, your charge for the assistance over three hours depends on it. You are expected to report the end time on your claims.
7. What was the time of the call to assist?
  • Your call-out charge depends on it. You must report it on your claims if billing call-out charges.
7. Was it out-of-province patient?
  • Certain procedures for reciprocal patients are not eligible for surgical assists.
8. Was the surgery abandoned?
  • Make sure to claim it. You still might be paid up to 50% of the fees. Ask the surgeon to submit a report.

Surgical Assist Payments by MSP Codes

00193 - NON-CVT CERT. SURGICAL ASSIST @ OPEN HEART SURGERY
$2.9M
00195 - SURGICAL ASSIST - LESS THAN $317.00 INCLUSIVE
$1.6M
00196 - SURGICAL ASSIST $317.01 TO 529.00 INCLUSIVE
$7.8M
00197 - SURGICAL ASSISTANCE - OPERATIONS OVER $529.00
$13M

BC, 2014/2015

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Disclaimer
The information contained herein has been drawn from sources known to be reliable, but the accuracy and/or completeness of the information is not guranteed, nor in providing it does TripleTee Software Company assume any responsibility or liability.