Assistant Surgeons and TRICARE

There are limitations on which provider types are authorized by TRICARE Management Activity (TMA) to function as assistant surgeons and when an assistant is covered by TRICARE.

The provider arranging for an assistant surgeon, whether it be a hospital, surgeon, or ASC facility, needs to be aware of the provider types recognized in the TRICARE program as assistant surgeons and only coordinate with those provider types. TMA acknowledges the following providers as assistant surgeons:

• Physicians
• Dentists
• Podiatrists
• Certified physician assistants
• Nurse practitioners
• Certified nurse midwifes

TMA does not accept the following providers as assistant surgeons:

• Certified Registered Nurse First Assistants (CRNFA)
• Registered Nurses (RN)
• Licensed Surgical Assistants (LSA)

In addition, standby assistant surgeon services are not reimbursed by TRICARE.

TMA has determined that services performed by assistant surgeons are covered:

• Based on the surgical procedure complexity and when the seriousness warrants an assistant surgeon
• When services can’t be accomplished by operating room nurses or other operating room personnel
• When interns, residents or other hospital personnel are not available to assist

Reimbursement

TRICARE’s auditing software, ClaimCheck, determines the need for an assistant surgeon. The reimbursement for assistant surgeon charges is as follows:

• The lower of billed charges or 16% of the prevailing charge (CHAMPUS Maximum Allowable Charge – CMAC) for the surgery (less any contractual discount)
• Multiple surgery rules apply
• Physician Assistants (PA) and Nurse Practitioners (NP) are reimbursed at 85% of the prevailing charge for a physician serving as an assistant surgeon, less any contractual discount. In other words, a PA or NP would be reimbursed at 85% of the 16% of the prevailing charge for the surgery, less any contractual discount.

For further information regarding assistant surgeons, please refer to the TRICARE Reimbursement Manual, Chapter 1, Section 6 and Chapter 1, Section 17 at www.tricare.mil.