CMS Pub. 100-04, ch. 12, § 100.1.7

A. General

A/B MACs (B) do not pay for the services of assistants at surgery furnished in a teaching

hospital which has a training program related to the medical specialty required for the

surgical procedure and has a qualified resident available to perform the service unless the

requirements of one of subsections C, D, or E are met. Each teaching hospital has a

different situation concerning numbers of residents, qualifications of residents, duties of

residents, and types of surgeries performed.

Contact those affected by these instructions to learn the circumstances in individual

teaching hospitals. There may be some teaching hospitals in which A/B MACs (B) can

apply a presumption about the availability of a qualified resident in a training program

related to the medical specialty required for the surgical procedures, but there are other

teaching hospitals in which there are often no qualified residents available. This may be

due to their involvement in other activities, complexity of the surgery, numbers of

residents in the program, or other valid reasons. A/B MACs (B) process assistant at

surgery claims for services furnished in teaching hospitals on the basis of the following

certification by the assistant, or through the use of modifier -82 which indicates that a

qualified resident surgeon was not available. This certification is for use only when the

basis for payment is the unavailability of qualified residents.

I understand that §1842(b)(7)(D) of the Act (follow the link and select the applicable

title) generally prohibits Medicare physician fee schedule payment for the services

of assistants at surgery in teaching hospitals when qualified residents are available to

furnish such services. I certify that the services for which payment is claimed were

medically necessary and that no qualified resident was available to perform the

services. I further understand that these services are subject to post-payment review

by the A/B MAC (B).

A/B MACs (B) retain the claim and certification for four years and conduct post-payment

reviews as necessary. For example, A/B MACs (B) investigate situations in which it is

always certified that there are no qualified residents available, and undertake recovery if

warranted.

Assistant at surgery claims denied based on these instructions do not qualify for payment

under the limitation on liability provision.

B. Definition

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). The conditions for coverage of such

services in teaching hospitals are more restrictive than those in other settings because of

the availability of residents who are qualified to perform this type of service.

C. Exceptional Circumstances

Payment may be made for the services of assistants at surgery in teaching hospitals,

subject to the special limitation in §20.4.3 notwithstanding the availability of a qualified

resident to furnish the services. There may be exceptional medical circumstances (e.g.,

emergency, life-threatening situations such as multiple traumatic injuries) which require

immediate treatment. There may be other situations in which the medical staff may find

that exceptional medical circumstances justify the services of a physician assistant at

surgery even though a qualified resident is available.

D. Physicians Who Do Not Involve Residents in Patient Care

Payment may be made for the services of assistants at surgery in teaching hospitals,

subject to the limitations in §20.4.3, above, if the primary surgeon has an across-the-

board policy of never involving residents in the preoperative, operative, or postoperative

care of his or her patients. Generally, this exception is applied to community physicians

who have no involvement in the hospital’s GME program. In such situations, payment

may be made for reasonable and necessary services on the same basis as would be the

case in a nonteaching hospital. However, if the assistant is not a physician primarily

engaged in the field of surgery, no payment be made unless either of the criteria of

subsection E is met.

E. Multiple Physician Specialties Involved in Surgery

Complex medical procedures, including multistage transplant surgery and coronary

bypass, may require a team of physicians. In these situations, each of the physicians

performs a unique, discrete function requiring special skills integral to the total

procedure. Each physician is engaged in a level of activity different from assisting the

surgeon in charge of the case. The special payment limitation in §20.4.3 is not applied.

If payment is made on the basis of a single team fee, additional claims are denied. The

A/B MAC (B) will determine which procedures performed in the service area require a

team approach to surgery. Team surgery is paid for on a “By Report” basis.

The services of physicians of different specialties may be necessary during surgery 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 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, and payment is made on a regular fee schedule basis.