CMS Pub. 100-04, ch. 12, § 100.1.2

In order to bill for surgical, high-risk, or other complex procedures, the teaching

physician must be present during all critical and key portions of the procedure and be

immediately available to furnish services during the entire procedure.

A. Surgery (Including Endoscopic Operations)

The teaching surgeon is responsible for the preoperative, operative, and postoperative

care of the beneficiary. The teaching physician’s presence is not required during the

opening and closing of the surgical field unless these activities are considered to be

critical or key portions of the procedure. The teaching surgeon determines which

postoperative visits are considered key or critical and require his or her presence. If the

postoperative period extends beyond the patient’s discharge and the teaching surgeon is

not providing the patient’s follow-up care, then instructions on billing for less than the

global package in §40 apply. During non-critical or non-key portions of the surgery, if

the teaching surgeon is not physically present, he/she must be immediately available to

return to the procedure, i.e., he/she cannot be performing another procedure. If

circumstances prevent a teaching physician from being immediately available, then

he/she must arrange for another qualified surgeon to be immediately available to assist

with the procedure, if needed.

1. Single Surgery

When the teaching surgeon is present for the entire surgery, his or her presence may be

demonstrated by notes in the medical records made by the physician, resident, or

operating room nurse. For purposes of this teaching physician policy, there is no required

information that the teaching surgeon must enter into the medical records.

2. Two Overlapping Surgeries

In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be

present during the critical or key portions of both operations. Therefore, the critical or

key portions may not take place at the same time. When all of the key portions of the

initial procedure have been completed, the teaching surgeon may begin to become

involved in a second procedure. The teaching surgeon must personally document in the

medical record that he/she was physically present during the critical or key portion(s) of

both procedures. When a teaching physician is not present during non-critical or non-key

portions of the procedure and is participating in another surgical procedure, he/she must

arrange for another qualified surgeon to immediately assist the resident in the other case

should the need arise. In the case of three concurrent surgical procedures, the role of the

teaching surgeon (but not anesthesiologist) in each of the cases is classified as a

supervisory service to the hospital rather than a physician service to an individual patient

and is not payable under the physician fee schedule.

3. Minor Procedures

For procedures that take only a few minutes (five minutes or less) to complete, e.g.,

simple suture, and involve relatively little decision making once the need for the

operation is determined, the teaching surgeon must be present for the entire procedure in

order to bill for the procedure.

4. Anesthesia

Medicare pays at the regular fee schedule level if a teaching anesthesiologist is involved

in a single procedure with one resident. The teaching physician must document in the

medical records that he/she was present during all critical (or key) portions of the

procedure. The teaching physician’s physical presence during only the preoperative or

postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If

an anesthesiologist is involved in concurrent procedures with more than one resident or

with a resident and a nonphysician anesthetist and the service is furnished prior to

January 1, 2010, Medicare pays for the anesthesiologist’s services as medical direction.

In those cases where the teaching anesthesiologist is involved in two concurrent

anesthesia cases with residents on or after January 1, 2004, the teaching anesthesiologist

may bill the usual base units and anesthesia time for the amount of time he/she is present

with the resident. The teaching anesthesiologist can bill base units if he/she is present

with the resident throughout pre and post anesthesia care. The teaching anesthesiologist

should use the “AA” modifier to report such cases. The teaching anesthesiologist must

document his/her involvement in cases with residents. The documentation must be

sufficient to support the payment of the fee and available for review upon request.

For anesthesia services furnished on or after January 1, 2010, payment may be made

under the Medicare physician fee schedule at the regular fee schedule level if the teaching

anesthesiologist is involved in the training of a resident in a single anesthesia case, two

concurrent anesthesia cases involving residents, or a single anesthesia case involving a

resident that is concurrent to another case paid under the medical direction rules. To

qualify for payment, the teaching anesthesiologist, or different anesthesiologists in the

same anesthesia group, must be present during all critical or key portions of the

anesthesia service or procedure involved. The teaching anesthesiologist (or another

anesthesiologist with whom the teaching physician has entered into an arrangement) must

be immediately available to furnish anesthesia services during the entire procedure. The

documentation in the patient’s medical records must indicate the teaching physician’s

presence during all critical or key portions of the anesthesia procedure and the immediate

availability of another teaching anesthesiologist as necessary.

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 in the appropriate field on the claim form.

The teaching anesthesiologist should use the “AA” modifier and the “GC” certification

modifier to report such cases. See §50 B. and §0 K.

5. Endoscopy Procedures

To bill Medicare for endoscopic procedures (excluding endoscopic surgery that follows

the surgery policy in subsection A, above), the teaching physician must be present during

the entire viewing. The entire viewing starts at the time of insertion of the endoscope and

ends at the time of removal of the endoscope. Viewing of the entire procedure through a

monitor in another room does not meet the teaching physician presence requirement.

6. Interpretation of Diagnostic Radiology and Other Diagnostic Tests

Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if

the interpretation is performed by or reviewed with a teaching physician. If the teaching

physician’s signature is the only signature on the interpretation, Medicare assumes that

he/she is indicating that he/she personally performed the interpretation. If a resident

prepares and signs the interpretation, the teaching physician must indicate that he/she has

personally reviewed the image and the resident’s interpretation and either agrees with it

or edits the findings. Medicare does not pay for an interpretation if the teaching

physician only countersigns the resident’s interpretation.