Wiki Please HELP - Teaching Attestation in co-surgery setting

[maryir]

I posted this thread yesterday under a different group and NO responses - there has to be someone out there that has an idea of at least where to look or what entity to ask.


Where would I be able to obtain guidelines relating the appropriate attestation to use for this scenario:

Two surgeons, working as co-surgeons, each having a resident assisting.

I believe that each attending should be stating why they required the assistance of a resident as another attending was in the room at the same time.

Now, my Manager and Director (and Compliance) are indicating that this is not a surgical assist situation and therefore no justification of the presence of a resident is required.

I've looked at the Medicare Teaching Guidelines and cannot locate anything specific to this type of scenario.

What governing body would have the definitive answer?

Any help would be greatly appreciated.

 

[Chelle-Lynn]

The documentation does not have to stated that the physician "required" the assistance of the resident. The resident is there to learn not to assist. If the resident performed part or all of the surgery, then this would need to be documented as any other teaching/resident situation, such as:

●They are furnished by a resident when a teaching physician is physically present during the critical or key portions of the service or ●They are personally furnished by a physician who is not a resident.

If the residents observed (with no hands on) then no reference needs to be made of their presence in the Op Room.

 

[maryir]

Thank you very much for the reply -

From your reply I now know I'm not clearly explaining the situation.

The residents are hands on.

My concern is that there are two attending's in the same surgical session at the same time there are residents participating in the surgical service.

My understanding of the teaching guidelines are: the attending surgeon must state why another attending is required when a second attending is actively participating in the surgical session (along with a resident).

That is the case 99.99% of the time when a second attending assist a colleague. This isn't an assist and that's where/why I'm getting pushback.

I hope I described the situation more clearly.

 

[Chelle-Lynn]

Gotcha! So if I am understanding your concern is:

* You have the primary Surgeon
* You have the assistant Surgeon
* You have the resident with primary surgeon (hands on)
* You have another resident with the assistant surgeon (hands on)

Your concern is in regards to how to document that in essence there were 4 surgeons in the room for this one patient.

If I have that correct, then here would be the requirement:

* Documentation should clearly state the need for the primary and assistant surgeon (as always)
* Documentation should clearly state the presence and services rendered by the two residents; one acting as a primary, one acting as assistant
* Justification is not required in regards to the presence of the residents as this is training only and not because of medical necessity.
* The only time we are required to justify the addition of an assistance is due to medical necessity such as the case of the prime/assistant surgeon.
* The present of a resident does not need to be medically justified.

 

[thomas7331]

Teaching guidelines aren't really my area of expertise, but if I'm understanding correctly, the reason the attestation is required for an assistant situation is because Medicare normally will not make payment to teaching hospitals for assistants at surgery under the expectation that the residents will assist. If the teaching hospital bills for an assistant at surgery by another attending, there has to be documentation to support that the circumstances were such that a resident either was not available or not able to function in the required capacity and a physician was necessary. But that is not the case for a co-surgeon - co-surgeons are performing components of a surgery which requires more than one specialty. It isn't necessary for a physician to document the need for a co-surgeon because each surgeon will have his or her own report which will support the work that each one did. A resident can never substitute for a physician as a co-surgeon, so there wouldn't be any reason to document why a resident or second physician was required in that situation. And I agree with Chelle - there is no need to justify the presence of the residents assisting, since you are not billing for assistant services in that case, only for the services of the two co-surgeons.

 

[maryir]

Thank you both for the information.

You've presented a way of looking at it that I wasn't taking full consideration of.

See, what I was considering/focusing on, is that the hospital gets paid (via GME) for the physician teaching the resident. Further, I knew that the assist wasn't being charged but having two attending's in the same session still makes me uncomfortable. Just don't want to cross any regulatory lines.

Your responses are very much appreciated. Don't know what I'd do without people like you.

Thanks,

Mary