CMS SOM App. W, Tag C-1142

The CAH designates the practitioners who are allowed to perform surgery for CAH

patients, in accordance with its approved policies and procedures, and with State

scope of practice laws. Surgery is performed only by--

(1) A doctor of medicine or osteopathy, including an osteopathic practitioner

recognized under section 1101(a)(7) of the Act;

(2) A doctor of dental surgery or dental medicine; or

(3) A doctor of podiatric medicine.

Interpretive Guidelines §485.639(a)

Surgical privileges should be reviewed and updated at least every 2 years. A current

roster listing each practitioner’s specific surgical privileges must be available in the

surgical suite and area/location where the scheduling of surgical procedures is done. A

current list of surgeons suspended from surgical privileges or whose surgical privileges

have been restricted must be retained in these area/locations.

The CAH must delineate the surgical privileges of all practitioners performing surgery

and surgical procedures. The medical staff is accountable to the governing body for the

quality of care provided to patients. The medical staff bylaws must include criteria for

determining the privileges to be granted to an individual practitioner and a procedure for

applying the criteria to individuals requesting privileges. Surgical privileges are granted

in accordance with the competencies of each practitioner. The medical staff appraisal

procedures must evaluate each individual practitioner’s training, education, experience,

and demonstrated competence as established by the CAH’S QA program, credentialing

process, the practitioner’s adherence to CAH policies and procedures, and in accordance

with scope of practice and other State laws and regulations.

The CAH must specify the surgical privileges for each practitioner that performs surgical

tasks. This would include practitioners such as MD/DOs, dentists, oral surgeons,

podiatrists, RN first assistants, nurse practitioners, surgical physician assistants, surgical

technicians, etc. When a practitioner may perform certain surgical procedures under

supervision, the specific tasks/procedures and the degree of supervision (to include

whether or not the supervising practitioner is in the same OR in line of sight) be

delineated in that practitioner’s surgical privileges and included on the surgical roster.

When practitioners whose scope of practice for conducting surgical procedures requires

the supervision of an MD/DO surgeon, the term “supervision” would mean the

supervising MD/DO surgeon is present in the same room, working with the same patient.

Surgery and all surgical procedures must be conducted by a practitioner who meets the

medical staff criteria and procedures for the privileges granted, who has been granted

surgical privileges in accordance with those criteria established by the governing body (or

responsible individual), and who is working within the scope of those granted and

documented privileges.

Survey Procedures §485.639(a)

• Review the CAH’S method for reviewing the surgical privileges of practitioners.

This method should require a written assessment of the practitioner's training,

experience, health status, and performance.

• Determine that a current roster listing each practitioner's specific surgical

privileges is available in the surgical suite and the area where the scheduling of

surgical procedures is done.

• Determine that a current list of surgeons suspended from surgical privileges or

who have restricted surgical privileges is retained in these areas/locations.