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.

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

Critical or Key Portion – That part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s). For purposes of this section, these terms are interchangeable.

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 Teaching Physician is involved in Overlapping Surgeries; The Critical or Key Portions of the Surgeries Do Not Overlap

When the Teaching Physician is involved in overlapping surgeries where the critical or key portions of the surgery do not overlap, the Teaching Physician must be physically present during the critical key portions of both procedures. All of the critical or key portions of the first procedure must be completed before the Teaching Physician can become involved in the second procedure.

If the Teaching Physician leaves the operating room to become involved in another case, he/she must arrange for another surgeon to be immediately available to intervene in the original case, if necessary. The Teaching Physician must document the critical or key portions of both procedures, and the immediate availability of the Teaching Physician and designated Teaching Physician.

The documentation must:

1. Reflect the Teaching Physician’s physical presence in both surgeries.
2. Identify in both operative reports the critical or key portions of the surgery (i.e. which part of the surgery required the teaching physician’s presence), and include either in the medical record or in another document the name of the other surgeon who was designated to be immediately available to intervene in the original case if necessary.

Teaching Physician is Involved in Overlapping Surgeries; The Critical or Key Portions Overlap.

The Teaching Physician may participate in two (2) overlapping surgeries but must be physically present during the critical or key portions of both procedures. If the critical or key portions of two surgeries overlap, neither procedure is reimbursable by Medicare.

Teaching Physician is Involved in Three or More Concurrent Surgeries.

The role of the Teaching Physician in three or more concurrent surgical procedures is considered a supervisory service to the hospital, rather than a physician service to an individual patient, and is not reimbursable by Medicare.

In all scenarios, it is important that operating room nurses keep accurate records regarding any change in surgeons during the procedure.

For billing purposes, the name of the performing surgeon must be consistent on the operating room record, the CMS billing form, and the written or dictated operative report.

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.