# Policy for residents as surgical assistants in a teaching facility



## LLovett (Oct 1, 2009)

My understanding is that in a teaching facility surgeons are to utilize qualified residents as their surigcal assistants when available. When not available and PAs or other MDs/DOs are used, there needs to be documentation in the op report as to why a resident was not used and you append the modifier 82 to the assistants charges.

Unless the surgeon has an across the board policy stating they do not use residents.

Is this correct? Can you have an across the board policy?

Now in my situation I have a group of surgeons that fall into both of the above categories.

This is a teaching facility but they don't have a cardiovascular program, so there are never qualified residents for those procedures. There is a general surgery program, so when the surgeons are doing thoracic cases they will use the residents if they are available (according to the surgeons they are rarely available).

What I would like to do is have an across the board policy stating residents are never used in cardiovascular cases. Then the providers are going to have document on each thoracic case why they didn't use a resident.

I am getting direction from a coding/compliance consultant on a national level that we can't do that, they need to document on every case since we can't have a true across the board policy.

I am just looking for other opinions/experiences and any guidelines that would support this either way. I don't personally care which way they need to do it, I just need to make sure it is correct before I present it. I have a lot of problems with these providers and getting them to follow the rules.


Thanks

Laura, CPC, CEMC


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## FTessaBartels (Oct 1, 2009)

*Documenting each case NOT onerous*

Laura,
I have never heard of having any blanket policy.  

I do not think it is unreasonable or onerous to require the surgeon to document on each operative report.  The phrase I see most often here is:
*In the absence of any qualified resident, PA XXX assisted in this case.* 

Our Compliance office assures us that this simple statement is sufficient. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## LLovett (Oct 2, 2009)

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6123.pdf

"Claims will be suspended and developed when billed by Method II teaching CAHs with modifiers AS, 80 or 81 to determine if exceptional medical circumstances existed or 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.
Given the absence of national policy on this provision, FIs and A/B MACs have the authority to establish procedures to define the appropriate supporting documentation needed to establish medical necessity, the existence of exceptional medical circumstances or to determine if the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his patients for assistant at surgery services. FIs and A/B MACs will also determine if a clinician or non-clinician medical reviewer will review assistant at surgery services."

http://www.cms.hhs.gov/Transmittals/Downloads/R1780B3.pdf

On pages 9 and 10 is the same info as above basically but it is for any teaching hospital not just Method II CAH.

While I agree it shouldn't be too difficult for them to add this to each note as appropriate, they have been advised by an outside agency that "excessive" use of the 82 modifier will trigger an audit. So they are pushing for a policy to keep from having to document each time and to not use the 82. 

I just don't know where to go with these guys. I have an external consultant saying one thing, an external coding company marching to the beat of a drum only they can hear, a national level consultant (within our hospital system) giving different direction from the other 2, and I get stuck holding the bag and looking bad.

I am leaning more towards us not being able to have an across the board policy since it would not truly be across the board.

Thanks

Laura, CPC, CEMC


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## FTessaBartels (Oct 2, 2009)

*Well. . .*

Well, what's "excessive" use?

Even if there's some sort of ability to have a blanket policy ... you are still in a teaching facility and you'll still need to use the -82 modifier. Or am I missing something?  Do they think if there is a blanket policy they won't need to use -82 but can use -80?  I've never heard of this. 

Even if an audit was triggered, it would be a no brainer if they have the "no qualified resident was available" statement on each op report, AND clear documentation that there is, in fact, no CV program at this teaching facility. 

Makes me wonder, what are they really afraid of?

Sorry I can't be more help.

F Tessa Bartels, CPC, CEMC


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## LLovett (Oct 5, 2009)

*Thanks Tessa*

They are afraid of a lot of things and for good reason...

If you have the policy of no residents ever you don't have to use the 82. In fact, although I have no idea why based on CMS guidelines, they have never used anything other than the AS modifier and have been getting paid. According to CMS they should be using the AS and the appropriate 80, 81, or 82. 

I would guesstimate they actually utilize residents in 1 out of every 50 cases. Do I believe it is because they aren't available more often, not really. I think it is personal preference of the surgeons and therefore it would be incorrect and unsupported to have a statement that there weren't any qualified residents available. Which is one of many reasons they don't want to draw anymore attention to themselves.

It is a less than desirable situation I currently find myself in, but I really appreciate you taking time to help me out.

Thanks

Laura, CPC, CEMC


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## SCanterbury (Oct 13, 2009)

Per Medicare, the across-the-board policy wasn't meant to apply to a whole group of physicians. This allowance was meant to apply to individual physicians, as appropriate, as explained here:

"_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 _[singular] _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_." (Manual 100-4, Chapter 12, Section 100.1.7 D. on p. 159 here)

Here's where you start:

If the department a) doesn't have a training/residency program, or b) does have a program but no qualified resident is available for this particular case, bill with -82 (AS is intended for use by non-physician practitioners).

If situation a), then the biller/coder can attach Modifier 82 to the claim without any supporting documentation by the physician. This is because 82 is not a modifier that necessarily has to be supported by documentation. Medicare specifically states that you can attest to the fact that no resident was available by saying so OR by simply using Modifier 82:

"_Carriers 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_."

If situation b), then the assistant surgeon who does his/her own code assignment can attach Modifier 82 to the claim, which as the quote above indicates, attests in-and-of-itself to the fact that no qualified resident was available, OR they can document an attestation in the record.

If a qualified resident is available, there are still three ways to be paid for an assistant surgeon at a teaching hospital. Since these allowances involve special situations in which a qualified resident often was available, Modifier 80 would be used instead of 82.

1) There is a residency program within the surgical department but 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_." 

2) The surgeon has a policy never to use residents, as explained above, usually because he/she is a community surgeon that has been invited in to perform a procedure. As such, he/she has no familiarity with any of the program's residents and is not accustomed to being assisted by a resident, which usually involves teaching/instruction as the procedure is performed. 

3) "_Complex medical procedures_...[requiring] _a team of physicians_...[with] _each physician...engaged in a level of activity different from assisting the surgeon in charge of the case._" 

Hope this has helped.

Seth Canterbury, CPC, ACS-EM
Education Specialist
University of Florida Jacksonville Physicians, Inc.
Clinical Data Quality-Education Department
653 West Eight Street
Tower I, Suite 606
Jacksonville, FL 32209
(904) 244-9643


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## LLovett (Oct 13, 2009)

*Thanks for the response Seth*

I appreciate you responding but I need help in applying the guidelines to my group.

I have all the guidelines and I think I understand them. What is causing the confusion is that this group falls under both categories.

The group is actually 2 surgeons and 4 PAs. They never use residents on cardiac cases because there aren't any that are qualified due to no program for that here. They will use residents for their thoracic cases if available because they do have a general surgery program here. The PAs are the ones that assist so we have to use AS in addition to the correct 8X modifier.

My understanding of the 82 was it had to be supported in the op report. You are saying it doesn't, is that correct? 

Thanks,

Laura, CPC, CEMC


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