Mid-Level Assistant

Please note this question was answered in 2017. The coding advice may or may not be outdated.


I am having a hard time locating solid resources for guidelines in regards to documentation requirements for a mid-level assistant during CTS/CV surgical services. Would documenting just the name of the mid-level assisting during the surgery be enough to suffice for the services? Or would our physicians need to document what the mid-levels did, the time spent assisting, and why they were needed during the service? Or, does the mid-level need to have his/her own entirely separate documentation of his/her work? I was hoping you can help alleviate this grey area and help find something solid for me to bring back to my doctors and mid-levels.

Question ID: 9386
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