Are There Special Documentation Requirements for an Assistant-at-Surgery?

Question:

We are seeking your advice on how to report to an assistant during surgery and what should be documented.

Answer:

Great question—this comes up often!

Two key points:

• If you are the assistant surgeon, you should not be dictating the operative note. That responsibility belongs to the primary or attending surgeon of record.

• The attending surgeon should include the assistant surgeon’s name in the designated assistant surgeon field and document the assistant’s role, providing details that support medical necessity.

Key takeaway: It is not sufficient to state, “Dr. XYZ assisted due to complexity.” This lacks specificity regarding the assistant’s role and does not describe the activities performed. Documentation should clearly outline what the assistant contributed during the procedure.

Determining the appropriate assistant modifier: both modifiers 80 and 82 indicate Assistant Surgeon. Modifier 82 is used explicitly in teaching hospitals with approved Graduate Medical Education (GME) programs for residents. In these settings, documentation must also confirm that no qualified resident was available to assist—this allows another physician to serve as the assistant surgeon, and modifier 82 should then be appended to that assistant surgeon’s claim.

In closing, please refer to your internal coding compliance guidelines to ensure adherence to the standards established by your compliance department.

Thank you for reaching out to KZA regarding your inquiry.

*This response is based on the best information available as of 01/22/26.

ICD-10 – Scar Contracture

Question:

Which ICD-10-CM diagnosis code should be reported for a patient undergoing release of a scar contracture on the flexor surface of the left elbow following healing from a third-degree burn?

Answer:

The scar contracture represents a sequela of the burn. According to ICD-10-CM guidelines, two codes should be reported:

1. L90.5 – Scar conditions and fibrosis of skin

2. T22.322S – Burn of third degree of left elbow, sequela

Key Points:

• ICD-10-CM guidelines instruct reporting the condition or nature of the sequela first, followed by the sequela code.

• Referenced guidelines: I.B.10 and I.C.19.d.7

In summary, reviewing ICD-10 guidelines ensures accurate coding and helps avoid common errors. These guidelines are a crucial resource for accurate code assignment.

Thank you for reaching out to KZA regarding your inquiry.

*This response is based on the best information available as of 01/08/26.

Complication: Back to OR

Question:

Can we bill separately for taking a patient back to the OR on postoperative day 2 to explore and repair a postoperative hemorrhage? I’ve heard that complications like this are usually included in the payment for the original surgery.

Answer:

Yes, you can bill for this. Both CPT and Medicare guidelines allow separate billing when a patient returns to the OR to treat a complication.

In this case, report the procedure code(s) for the services performed to address the postoperative hemorrhage. Be sure to append modifier 78 to indicate an unplanned return to the OR and assign the appropriate ICD-10 code for postoperative hemorrhage.

Thank you for reaching out to KZA regarding your inquiry.

*This response is based on the best information available as of 12/18/25.

Closure After a Partial Mastectomy, Code 19301

Question:

Adjacent tissue transfers, 14000 series to include 14301 and 14302 with 19301 Mastectomy. I see where you clarify 14000 (ADJ flaps) to eliminate dead space is inherent to a mastectomy procedure. My question is does this include codes 14301 and 14302? I'm asking because there was a Q & A 2017 CPT Assistance Article stating "14000 and 14001 are not reported separately because simple, intermediate and complex layered closure is included in the work represented by code 19301". As such, our guidance is that it is ok to bill separately for codes 14301 and 14302 with 19301 when the defect is larger than 30 sq cm.

Answer:

This is a common misunderstanding. It does not matter how large a defect remains after a partial mastectomy, closure by a local advancement flap or an oncoplastic repair do not support an adjacent tissue transfer. Codes 14301, 14302 should not be reported for these closures regardless of the size of the defect.

See below for guidance from the American College of Surgeons national coding courses.

• There are no additional codes for closure after a partial mastectomy, code 19301

• Elimination of dead space is inherent to a mastectomy procedure.

• Complex closure (13100-13102, 13131-13133) is included in any mastectomy procedure.

• Local advancement flaps and oncoplastic repair are included in a mastectomy procedure.

• Adjacent tissue transfer (ATT) (14000-14302) is not commonly performed with a mastectomy (e.g., 19120, 19125). A closure defined as a local advancement flap or an oncoplastic repair is most commonly a skin advancement flap that does not meet the definition of a true ATT.

• If a complex repair is substantially greater than typically required, it may be appropriate to append modifier 22, Increased Procedural Services, to the mastectomy code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required.

*This response is based on the best information available as of 12/04/25.

KX Modifier?

Question:

Should the KX modifier be billed on all feminization procedures in the setting of gender dysphoria? For example, feminization rhinoplasty for a trans female patient assigned male at birth.

Answer:

In the context of gender-affirming surgery, the KX modifier should be appended to procedure codes that are gender-specific—particularly when there is a mismatch between the patient’s gender marker and the procedure or diagnosis code. This modifier alerts the payer that the coding is intentional and not an error.

In the example provided—feminization rhinoplasty for a trans female patient—there is typically no conflict between the gender marker and the procedure or diagnosis code. As such, the KX modifier would generally not be necessary.

It’s important to note that modifier KX indicates that “requirements specified in the medical policy have been met.” This modifier is not exclusive to gender-affirming procedures and may be used in other contexts.

In closing, always consult the payer-specific policy and your internal coding compliance guidelines to ensure accurate and compliant use of modifiers.

Thank you for contacting KZA!

*This response is based on the best information available as of 11/20/25.

Automated Skin Cell Suspension Autograft Procedures

Question:

A provider at our facility has begun performing the new 2025 skin cell suspension autograft procedure. During this process, automated preparation of the autograft is performed, including enzymatic processing, disaggregation of skin cells, and filtration of harvested tissue. Currently, there is no specific CPT code that describes this work. Since we are advised to report an unlisted code for this service, what comparative CPT code would you recommend using to help determine appropriate reimbursement?

Answer:

For SCSA procedures using automated preparation devices, report the harvest codes (15011-15012) and application codes (15015-15018) based on the surface areas involved. Do not report the preparation codes 15013-15014 when automated devices are used, as these codes are exclusively reserved for manual mechanical disaggregation of skin cells.

According to CPT Assistant (December 2024, June 2025), the Skin Replacement Surgery subsection guidelines explicitly state that codes 15013-15014 "are not reported if the harvested skin is nonmanually processed (i.e., using automation)." When automation is used, only the physician's work in harvesting and application is separately reportable.

*This response is based on the best information available as of 11/06/25.