DEFINITIONS

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

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

The teaching anesthesiologist must document in the medical record that he/she was present during all of the key or critical portions of the anesthesia service or procedure.  The critical portions are defined as, presence during the induction, emergence, and any other key portion of the procedure. In addition, the teaching anesthesiologist must be immediately available to furnish anesthesia services during the entire procedure.

The time unit for each procedure is the value of actual time expended. Time units are reported in fifteen (15) minute increments. Anesthesia time begins when the anesthesiologist, resident or CRNA begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist, resident or CRNA is no longer in personal attendance.

For concurrent procedures in which faculty may be supervising more than one resident, faculty must indicate the number of cases they are medically directing at one time on the encounter form. The teaching anesthesiologist may bill the usual base units and anesthesia time for the amount of time he/she is present with the resident. In this instance, the teaching anesthesiologist may bill base units if he/she is present with the resident throughout pre and post anesthesia care. The teaching anesthesiologist must document his/her involvement in cases with residents.

Effective January 1, 2010 the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents.

For billing purposes, the Anesthesiologist can direct no more than four (4) anesthesia procedures concurrently. The role of the Teaching Anesthesiologist [in five (5) concurrent surgical procedures] is considered a supervisory service to the hospital, rather than a physician service to an individual patient and is not reimbursable under Medicare’s physician fee schedule.

For pre-op services where a time lag exists between the services delivered and the beginning of surgery, actual time for pre-operative services/procedures (i.e. epidural) must be charged on the medical record. This additional time will be included for billing purposes.

The teaching physician must be present for the “key” portions of the anesthesia administration and the medical record must indicate the teaching physician’s presence. It is up to the individual physician’s judgment on a case-by-case basis as to what constitutes “key” portions. “Key” portions can fall anywhere between and inclusive of pre-operative to post-operative visits.

If different teaching anesthesiologists are present with the resident during the key or critical periods of the resident case, the NPI of the teaching anesthesiologist who started the case must be indicated on the claim form.

The teaching anesthesiologist should use the “AA” modifier and the “GC” certification modifier to report such cases.

Modifiers for use in Anesthesia Service

AA – Anesthesia Services performed personally by the anesthesiologist;

AD – Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;

G8 – Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures;

G9 – Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition;

QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;

QS – Monitored anesthesia care service;

QX – CRNA service; with medical direction by a physician;

QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist;

QZ – CRNA service: without medical direction by a physician; and

GC – These services have been performed by a resident under the direction of a teaching physician.

The GC modifier is reported by the teaching physician to indicate he/she provided a  service in accordance with the teaching physician requirements. Modifier GC should be used in conjunction with one of the above anesthesia modifier.

The following services are also billable by either the anesthesiologist or the CRNA:

1. Swan Ganz Catheter;
2. Central Venous Pressure Lines (independent of a Swan Ganz catheter);
3. Arterial Line Placement;
4. Emergency intubation;
5. Critical Care Services (not billable by the CRNA or resident); and
6. Pre-anesthesia exam of a patient who does not undergo 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)

Medicare Carriers Manual: 3350.5

Medicare Claims Processing (PUB. 100-04)
Chapter 12 – Physicians/Nonphysician Practitioners
50 – Payment for Anesthesiology Services (Updated through Rev. 1859; Effective: This provision is effective for services furnished on or after January 1, 2010; Issued: 11/20/09)