Why you should consider a PA to first assist in surgery

A surgical first assistant plays an integral role in the surgical team. Physicians have several options for how to fill and use the position. An option that should be considered is utilizing a physician assistant (PA) as a first assistant. As a PA myself, I feel it is important that physicians are aware of this option and understand its benefits.

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There are many options for a surgical first assist, including an another physician, a fellow or resident physician, a PA, surgical assistant-certified (SA-C), and registered nurse first assistant (RNFA).

Why should you consider using a PA as your first assist? Here are some reasons:

• PAs first assisting at surgery are usually reimbursed at 85-100% of the first-assist fee paid to a physician acting as the first assistant (which is generally 16% of the primary surgeon fee).

• PAs bill for their services at the full physician fee schedule. They should use their national provider identifier number and the “AS” surgical assistant billing modifier. The Medicare carrier or Private payer will implement the appropriate discount. For more information, see the Medicare Claims Processing Manual, Chapter 12, Section 110.3 or Private payer manual.

• Using a PA as a first assist will free up a physician to schedule more surgeries or see more clinic patients, thereby generating more revenue and decreasing patient wait times.

• PAs who first assist are better familiarized with the perioperative and intraoperative care of patients, allowing them to provide more comprehensive patient education and care in the preoperative and postoperative setting.

• Many PAs desire a multifaceted working environment. Encouraging professional development and growth by perfecting a new skill can boost morale and job satisfaction. Varying the PA’s schedule with clinic, procedures, inpatient work, and OR time can be very rewarding. Job satisfaction will help with employee recruiting and retention leading to less turnover.

When can you use a PA as a first assist?

PAs are eligible for reimbursement for first assisting in any procedure where a physician would receive such reimbursement (American Association of Physician Assistants)(CMS).

You may also consult the Physicians as Assistants at Surgery 2016 Update , which assigns all surgeries with CPT codes a ranking of whether or not they require a physician as a first assistant: 1 - almost always, 2 - almost never, or 3 - some of the time. There is also an excerpt called “Surgical Assistants” from the American College of Surgeons Statements on Principles regarding the qualifications of surgical assistants, including non-physician providers.

In teaching hospitals, Medicare restricts coverage of PAs for first assisting at surgery. There are no restrictions for other services PAs provide. If a teaching hospital has an approved and accredited surgical training program related to the surgery being performed and has a qualified resident available to perform the service, no reimbursement is made for a PA first assisting.

If the primary surgeon has a policy of never allowing residents to act as assistants, or in trauma cases, or if the surgeon believes that the resident is not the best individual to perform the service, Medicare will reimburse for a PA first assistant. In these cases, claims should be accompanied by an explanation that the first assist was medically necessary and that no qualified resident was available to first assist at that time. Medicare requires the following attestation in the operative report:

“I understand that section 1842(b)(7)(D) of the Social Security Act generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post-payment review by the Medicare carrier.”

For more information regarding PAs assisting in Teaching Settings, see the Medicare Claims Processing Manual Chapter 12, Section 100.1.7.

Next: PA training in first assisting

PA training in first assisting

How do PAs get trained in first assisting? There are three ways:

• Many PAs are exposed to surgery during PA school as PA programs require surgical rotations. This may include observation and hands-on experience. If hiring a new graduate, ask to review any procedure logs they may have kept as a student.

• There are postgraduate PA training programs in various surgical subspecialties including urology that integrate first assist training into their curriculum.

• The majority of PAs receive on-the-job training by their supervising physician(s) and by experienced PAs already employed by the practice. There is no mandated or standardized approach for on-the-job training as it varies from practice to practice and must comply with hospital credentialing policies.

My experience

I completed training at the UT Southwestern Urology PA Postgraduate Fellowship program, which included procedural and operative training. By the completion of my yearlong training, I felt comfortable to first assist on the majority of robot-assisted laparoscopic surgeries applicable to urology, including prostatectomy, cystectomy, partial nephrectomy, pyeloplasty, and sacrocolpopexy. My training progressed from observation to MD/PA-supervised assisting (typically I and another qualified PA double scrubbed at the bedside) and then independent first assisting.

Related: How to use (and how not to use) urology PAs

The first 3 months of the program, I mostly observed and did some assisting with another PA present and scrubbed. This would take place anywhere from one to three times weekly. As my knowledge and ability increased, my supervising PA took less of an active role.

After getting to the point where the supervising PA no longer had to scrub but was present just to observe, I then transitioned to first assisting without another PA. As I was in a dedicated training program, this process was about 6 months to independent first assisting. However, I do not think the training process always needs to be that lengthy. If training a new graduate or PA without surgical assisting experience, consider additional online training courses and conferences to supplement on-the-job training. For example, Intuitive Surgical, via its da Vinci Surgery Online Community, offers free training modules, full-length surgery videos, and information on upcoming conferences.

You may also consider reducing clinic and inpatient responsibilities during the training period to maximize OR exposure.

Participating in the OR as a first assist has greatly enriched my career and job satisfaction as well as my understanding of urologic surgery and my ability to counsel patients.

Physicians, I hope after reading this you will consider adding a PA to your surgical team.

PAs, I hope you will consider discussing the possibility of first assisting with your physician team.

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