How do you define “No Qualified Resident Available”?

How do you define “No Qualified Resident Available”?

August 8, 2019

Our physicians utilize residents during surgery but we have a discrepancy in what is considered a “Qualified Resident”. Some physicians consider a resident qualified to assist day 1 of their residency rotation, while others consider only 4th and 5th year residents as qualified to assist. Can you guide us to documentation that clarifies this for our orthopedic surgeons so that they are documenting on their operative notes properly and the assistants are billed only when a qualified resident is not available?

Look to the Medicare carrier manual for guidance. Section 1780 E states: (bolding added for educational purposes)

“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.”

It appears that this would be part of the institution’s compliance plan for standard procedures and there shouldn’t be wide variation within an institution. The same section notes some reasons why there may not be a qualified resident 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.”

The certification required to support billing for an assistant in a teaching institution follows:

“I understand that section 1842(b)(7)(D) of the Social Security Act 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 Medicare carrier.” Retain the claim and certification for four years and conduct post-payment reviews as necessary.

*This response is based on the best information available as of 08/08/19.

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