[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR415.172]



[Page 805-806]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 415_SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING 

PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS

--Table of Contents

 

            Subpart D_Physician Services in Teaching Settings

 

Sec. 415.172  Physician fee schedule payment for services of teaching 

physicians.



    (a) General rule. If a resident participates in a service furnished 

in a teaching setting, physician fee schedule payment is made only if a 

teaching physician is present during the key portion of any service or 

procedure for which payment is sought.

    (1) In the case of surgical, high-risk, or other complex procedures, 

the teaching physician must be present during all critical portions of 

the procedure and immediately available to furnish services during the 

entire service or procedure.

    (i) In the case of surgery, the teaching physician's presence is not 

required during opening and closing of the surgical field.

    (ii) In the case of procedures performed through an endoscope, the 

teaching physician must be present during the entire viewing.

    (2) In the case of evaluation and management services, the teaching 

physician must be present during the portion of the service that 

determines the level of service billed. (However, in the case of 

evaluation and management



[[Page 806]]



services furnished in hospital outpatient departments and certain other 

ambulatory settings, the requirements of Sec. 415.174 apply.)

    (b) Documentation. Except for services furnished as set forth in 

Sec. Sec. 415.174 (concerning an exception for services furnished in 

hospital outpatient and certain other ambulatory settings), 415.176 

(concerning renal dialysis services), and 415.184 (concerning 

psychiatric services), the medical records must document the teaching 

physician was present at the time the service is furnished. The presence 

of the teaching physician during procedures may be demonstrated by the 

notes in the medical records made by a physician, resident, or nurse. In 

the case of evaluation and management procedures, the teaching physician 

must personally document his or her participation in the service in the 

medical records.

    (c) Payment level. In the case of services such as evaluation and 

management for which there are several levels of service codes available 

for reporting purposes, the appropriate payment level must reflect the 

extent and complexity of the service when fully furnished by the 

teaching physician.