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Frequently Asked Questions

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In a Teaching Hospital setting, what documentation needs to be indicated in the medical record for an assistant surgeon when a qualified resident is not available?

In AMC (Academic Medical Centers), there are times when a surgical procedure is so complex that it requires multiple surgeons. Generally the expectation is that a resident(s) would be used to assist with the surgery. If no resident(s) are available, the resident(s) available are not sufficiently qualified to provide the needed assistance or the attending physician never uses residents then an attending can be used to assist with the surgery.  When billing for such assistant surgeon services, one of the following must be documented in the medical record:
    • A statement that no qualified resident was available to perform the service
    • A statement indicating that exceptional medical circumstances exist
    • A statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients


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