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.

Help! Can You Clarify Radiology Documentation Requirements?

Question:

We are just looking for clarification of the Interpretation for Radiology services. We have been including them in our E/M notes for years. Can you please explain exactly what it is payors like UHC are requesting/requiring? Are they wanting a report of that Radiology exam on a separate form altogether?

Answer:

You're not the only one who has been including the interpretation in the E/M.

CPT guidelines in the introductory section of the radiology chapter 70000-79999 states a written report signed by the interpreting individual is considered "an integral part of a radiologic procedure or interpretation." This means radiology interpretation requires formal, separate documentation—not just findings mentioned within an E/M note. The written report must contain interpretive findings and documentation of the imaging performed.

The CPT exception is if the CPT code includes imaging. For example, CPT 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting includes image guidance. Since the imaging is part of the procedure, you document the imaging guidance within your procedure note rather than as a separate radiology report.

This is also consistent with CMS where the payment conditions for radiology services where Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures states: "The interpretation of a diagnostic procedure includes a written report.”

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

History of Skin Cancer — Low or Moderate Complexity

Question:

I have a question about history of skin cancer and the complexity of the problem. If a patient comes in for follow up for history of skin cancer and the physician does a full skin exam, is the complexity low or moderate?

Answer:

Thank you for your question. The history of skin cancer is considered a chronic condition. However, the determination between low complexity and moderate depends on the condition. If the physician exams the patient and there is no evidence of a recurrence the complexity is low (chronic stable). But if the physician discovers another skin cancer or suspects cancer, the complexity is now moderate (chronic, exacerbating). Keep in mind the complexity of the problem addressed is only one element. There are two other elements, amount and/or complexity data to be reviewed and analyzed and risk of complications and/or morbidity or mortality of patient management which goes into determining the overall level of service. Two of the three elements must be met when determining the level of service based on medical decision making.

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

Is the ICD-10-CM code enough?

Question:

I am reaching out to ask if a provider lists the ICD-10-CM code with code description on the encounter under the Assessment and Plan if this is sufficient to use as their documentation and would this pass in an audit?

I do not believe this meets the ICD-10-CM guidelines and would like some clarification that I'm not querying erroneously.

Thank you in advance for your response to this matter!

Answer:

Thank you for your query, it is a great question.

No, it is not sufficient for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. The AHA coding clinic, specifically the 4th quarter of 2015, states that the ICD-10 codes are "statistical classifications, not replacements for a provider's written diagnosis."

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

Documenting Occlusions for 2026 Lower Extremity Endovascular Revascularization Coding

Question:

The CPT guidelines for the lower extremity endovascular revascularization codes state that a straightforward lesion is a stenosis and a complex lesion is an occlusion. When documenting treatment of an occlusion, must the operative report specify the degree of blockage (for example, 100% or total), or does documentation of the lesion as an occlusion alone support reporting a complex lesion?

Answer:

Documentation of the lesion as an occlusion alone is sufficient to support reporting treatment of a complex lesion. CPT defines lesion complexity by lesion type, not by a percentage of narrowing, and an occlusion by definition represents complete blockage. CPT does not require documentation of “100%” or “total” for code selection. That said, because these codes are newly implemented, providers and coders should continue to monitor local MAC and commercial payer policies for any additional documentation requirements as payers begin to adjudicate claims.

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

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.