Second Surgical Assistant for Cardiovascular Bypass Procedures under California Title 22

This applies to California only.

Noridian has become aware of the difficulties for some California cardiopulmonary bypass surgeons and facilities being created by California's Title 22, §70435 (b)(2) and (b)(4).

Title 22 - Social Security California Code of Regulations - Division 5

§70435. Cardiovascular Surgery Service Staff

  1. Cardiovascular catheterization laboratory.
    1. ...
  2. Cardiovascular operative service.
    1. A physician shall have overall responsibility for the service. This physician shall be certified or eligible for certification by the American Board of Thoracic Surgery or the American Board of Surgery with training and experience in cardiovascular surgery. He shall be responsible for:
      1. Implementing established policies and procedures.
      2. Training and supervising the nurses and technicians in special techniques.
      3. Training and supervising the clinical perfusionists.
    2. A minimum of three surgeons shall constitute a surgical team for the performance of all cardiovascular operative procedures which require extracorporeal bypass. At least one surgeon must meet the requirements outlined in subparagraph (b) (1) above.
    3. Anesthesia for cardiovascular procedures shall be administered by a physician who is certified or eligible for certification by the American Board of Anesthesiology.
    4. A physician who is certified or eligible for certification in cardiology by the American Board of Internal Medicine should be a member of the surgical team and should assist in monitoring the patient.
    5. Clinical perfusionists shall operate the extracorporeal equipment under the immediate supervision of the cardiovascular surgeon or cardiologist.

Unfortunately, a single state law that is outdated compared with the standard of care for the rest of the country does not give rise to satisfying Medicare's requirement for medical necessity.  We do understand that a denial of a second assistant on the basis of no medical necessity is a change for some California providers.  Therefore, on an interim basis, until such time as a longer-term remedy can be found for the situation, Noridian will pay for the additional assistant at appeal (technically under "individual consideration" which requires that an approval be at the redetermination level), if the appeal is submitted with any one (or more) of the following:

  1. An original operative note (appropriate record in all respects, containing patient name, procedure, signed, dated, etc.) that makes it clear who assisted on the case, clarifying the role that the assistant filing the claim had in the procedure (we have had many operative notes that don't even mention the assistant, or are unsigned, undated, etc. which clearly is not sufficient), or
  2. An amendment to the operative note, again, appropriately signed and dated, making it clear to which specific surgical case it applies, and providing the same information clarifying the role that the assistant filing the claim had in the procedure, or
  3. A copy of the surgical nursing note if it provides this same information, or
  4. A new operative note from the surgical assistant, proving this same information.

It is understood that options (2) and (4) will follow the surgery by some period of time, but this will be accepted as an interim measure until there is a better way to address these issues).

 

Last Updated Aug 14 , 2018