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.