How to report assistant surgeon for the procedure in medical coding

For Coding and billing for Assitant, you need to check following

1. Check the eligiblity of the CPT for assistant modifier such as AS or 80 in encorder tool.

2. Check the attestation or the work that is performed by the assistant, without assistant it will be incorrect and need to query to the provider.

Format of Op Report for attestation :

Operative report Sample

Patient Name: John Sedan

Age/Sex: 52/M

MRN No: 12345

Date of Surgery:27 Feb 2026

Preoperative Diagnosis :  Right shoulder osteoarthritis

Postop diagnosis : Right shoulder osteoarthritis

Procedure Performed: Total Shoulder Arthroplasty

Primary Surgeon: Dr. Rajeev Kumar, MS (Orthopedics)

Assistant Surgeon: Dr. Ananya Mehta, MS

Nurse: Ms. Priya Singh

Nurse: Ms. Neha Das

Anesthesia: General anesthesia with interscalene regional block.

Indications for Surgery:The patient presented with chronic shoulder pain, stiffness, reduced range of motion, and radiological evidence of advanced glenohumeral arthritis refractory to conservative management.

Procedure Details :After informed consent was obtained, the patient was shifted to the operating room and positioned in the beach-chair position with appropriate padding of pressure points. The operative shoulder and upper limb were prepared with antiseptic solution and draped in a sterile fashion.

A standard deltopectoral approach was used. Skin incision was made from the coracoid process extending distally along the deltopectoral groove. The cephalic vein was identified and retracted laterally with the deltoid. The clavipectoral fascia was incised, and the conjoint tendon was retracted medially.The subscapularis tendon was identified, tagged with non-absorbable sutures, and released via tenotomy near its insertion. The anterior capsule was incised, and the glenohumeral joint was exposed. The humeral head was dislocated anteriorly.An oscillating saw was used to perform humeral head osteotomy at approximately 30–40 degrees of retroversion relative to the humeral shaft. Sequential reaming of the humeral canal was carried out, followed by broaching to appropriate size ensuring proper alignment and version.

Attention was then turned to the glenoid. Labral tissue was excised circumferentially, and the glenoid surface was exposed. A central guide pin was placed, and reaming was performed to achieve a congruent surface with correction of version as needed. Peg holes were drilled, and the glenoid component was implanted using bone cement, ensuring stable fixation.

Trial humeral components were inserted, and reduction was performed to assess stability, soft tissue balance, and range of motion. Appropriate size and version were confirmed.

The definitive humeral stem was then inserted (cemented/press-fit as appropriate), followed by placement of the humeral head component. The joint was reduced, and stability through a full range of motion was confirmed.The subscapularis tendon was repaired using transosseous sutures. Thorough irrigation was performed. Hemostasis was achieved. A suction drain was placed as required.

Layered closure was performed—deltopectoral interval, subcutaneous tissue, and skin using appropriate sutures. Sterile dressing was applied, and the arm was placed in a shoulder immobilizer.

Estimated Blood Loss:Approximately 250 ml

Complications:None

ATTESTATION

1. Dr. Ananya Mehta (Assistant Surgeon)** assisted in exposure, humeral preparation, glenoid component placement, and wound closure.

2. Ms. Priya Singh (Scrub Nurse)** maintained strict asepsis and ensured timely and accurate instrument handling throughout the procedure.

3. Ms. Neha Das (Circulating Nurse)** coordinated intraoperative requirements, patient monitoring interface, and documentation.