Teaching Physician – A  physician (other than another resident) who involves residents in the care of his or her patients

Resident – An individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the Fiscal Intermediary. Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident”. Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents

Critical or Key Portion – CMS defines “critical or key portion” as the segment of the service/procedure that the teaching physician determines is critical in his/her judgment and requires his/her presence. CMS also recognizes that sometimes opening or closing of the patient may constitute the “key portion” of the surgery.

Physically Present – The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

STANDARD

The operative report should indicate the actual surgeon as the “Physician performing the service.” If the resident or fellow performing the procedure is capable of performing the procedure without supervision, then the teaching physician would not be eligible to receive reimbursement under Part B for supervision purposes, since his/her presence is superfluous. However, if the teaching physician’s presence is medically necessary, then the teaching physician may bill under Part B, provided the medical necessity of the teaching physician’s presence is clearly documented in the medical record.

For simple or minor procedures (procedures that are less than 5 minutes in duration) that involve little decision-making (i.e., simple suture) the teaching physician must be present for the entire procedure in order to bill for the procedure. CMS recommends the teaching physician document his or her involvement in a minor surgical procedure in the progress note.  However, the teaching physician’s physical presence may also be demonstrated by notes made by the resident or nursing staff.

In the case of major or complex procedures (procedures that are 5 minutes or greater in duration), the teaching physician must be present during all critical portions of the procedure and must be immediately available to furnish services during the entire service.

If the Teaching Physician is present for the entire procedure, his/her presence can be demonstrated by notes made by the Teaching Physician, Resident or Nursing Staff. If the Teaching Physician is present only for the key portion of the procedure, the procedure note must include a statement by the teaching physician which:

1. Identifies the critical or key portion,
2. Personally attests to his/her presence during the critical or key portion; and
3. Reflects immediate availability to return to the procedure, or designates another physician to be immediately available to assist in the procedure, if needed.

During the period in which a teaching physician’s presence may not be required, he/she must be “immediately available” and must not get involved in another procedure from which he/she cannot return, unless another physician is designated.

The inclusion of the explanatory statement in the operative report will support the attestation statement in the event of an audit.

For purposes of this standard, there is no required information the teaching physician must enter into the medical record. However, it is recommended that the teaching physician write in the medical record that he/she was present for the critical portion of the procedure and was not involved in any other concurrent procedure.

CMS does not define the term “immediately available” but recommends, documentation in writing “at hand” or “in the surgical suite” to indicate the teaching physician’s availability. The operative note must indicate the time the teaching physician was present during the procedure. A teaching physician may only be “immediately available” in connection with one procedure at any given time.

REGULATORY REFERENCES

Medicare Claims Processing (PUB. 100-04)
Chapter 12 – Physicians/Nonphysician Practitioners
100 – Teaching Physician Services (Updated through Rev. 2303 **Rescinds and Replaces Transmittal #2247, dated 06/24/11**; Effective: 06/01/11; Issued: 09/14/11)

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.