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

Assistant at Surgery – An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under State law can also serve as an assistant at 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.

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.

STANDARD

Payment on a fee schedule basis is made for the services of an assistant at surgery in a teaching hospital only if the services meet one of the following conditions:

1. Are required as a result of exceptional medical circumstances, e.g., emergency, life-threatening situations such as multiple traumatic injuries which require immediate treatment.
2. Complex medical procedures by a team of physicians, each performing a discrete, unique function integral to the performance of a complex medical procedure that requires the special skills of more than one physician. Team surgery is paid for on a “by report” basis.
3. Constitute concurrent medical care relating to a medical condition that requires the presence of, and active care by, a physician of another specialty during surgery.
4. Are medically required and are furnished by a physician who is primarily engaged in the field of surgery and the primary surgeon has an across-the-board policy of never using interns or residents in the surgical procedures that the surgeons performs (including pre-operative and post-operative care).
   • NOTE: Generally, this exception is applied to community physicians who have no involvement in the hospital’s GME program. In a teaching environment, use of assistants at surgery is not appropriate and should be applied on an exception basis.
5. Are not related to a surgical procedure for which CMS determines that assistants are used less than five (5) percent of the time.
6. A qualified resident was not available.

Except as noted above, payment under Part B is not available for assistants at surgery in hospitals with:

1. a training program relating to the medical specialty required for the surgical procedure and
2. a resident in a training program relating to the specialty required for the surgery available to serve as an assistant at surgery.

The teaching physician should document in the content of the operative report the involvement of a non-resident in the surgery.  This statement should briefly describe the circumstance; such as, critical nature of patient’s condition, unusual procedure or anatomy, resident involvement in other procedures, or, resident of appropriate specialty not available. The operative report should also indicate the name of the primary surgeon and assistant surgeon(s).

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

There are some situations when the services of physicians of different specialties are necessary during surgery and when each specialist is required to play an active role in the patient’s treatment because of the existence of more than one medical condition requiring diverse, specialized medical services. For example, a patient’s cardiac condition may require that a cardiologist be present to monitor the patient’s condition during abdominal surgery. In this type of situation, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery.

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.