Simultaneous. Double-booked. Running two rooms. There are many terms used to describe the practice of overlapping and concurrent surgeries — a situation in which a senior physician schedules and conducts operations on two different patients at the same time.
Though overlapping surgery is fairly common, up until recently there had been little awareness of it beyond the medical community. That changed when The Boston Globe issued an article in December 2015 alleging that the practice might have been responsible for several significant instances of patient harm in Boston – including death.
Distressed by the allegations in the article, the Senate Finance Committee (SFC) — which has jurisdiction over the Medicare and Medicaid programs — launched an initial inquiry. The SFC reached out to 20 teaching hospitals and examined guidance issued by the Centers for Medicare & Medicaid Services (CMS) as well as the American College of Surgeons (ACS) to better understand the policies and practices of overlapping surgery. Their findings were codified in a report issued December 2016 titled, "Concurrent and Overlapping Surgeries: Additional Measures Warranted."
Today, overlapping surgeries present a certain crisis in terms of billing. Per the American Hospital Association, most hospitals participate in Medicare and Medicaid, which account for more than half of all care provided. Hospitals must comply with the Medicare Conditions of Participation (COP), a set of health and safety guidelines that outlines acceptable standards for surgical services and defines the rights of patients in the consent of their treatment. If a hospital does not comply, and a surgery fails to align with the documentation requirements put forth in the COP, then the hospital puts itself at risk for possible reimbursement.
Defining a Surgery
According to the CMS Medicare Claims Processing Manual, there are certain circumstances that enable a teaching physician to bill Medicare for overlapping surgeries. The most notable circumstances are paraphrased below:
- The teaching physician must be physically present during all critical portions of the procedure and "immediately available" during the entire procedure.
- The critical portions of two surgeries performed by the same teaching physician may not take place at the same time.
- If circumstances prevent the teaching physician from being immediately available, then he or she must arrange for another qualified surgeon to replace him/her, if needed.1
But note that the circumstances do not define what the "critical portions" of a procedure are, nor do they elaborate on what it means to be "immediately available."
When it comes to defining "immediately available," the ACS states: "Immediately available means reachable through a paging system or other electronic means and should be defined more completely by the local institution." However, the CMS definition is a bit more vague. It states, "Immediately available is generally not defined except to indicate that a surgeon performing another procedure would not be considered to be immediately available."2 Meanwhile, among the 17 hospital policies that the SFC reviewed, nearly a third defined "immediately available" as being on campus, three did not specify, and one defined the term as being available within five to fifteen minutes.3
This perception gap between the ACS and CMS has led to hospitals placing a heavy emphasis on semantics when it comes to their documentation process — going above and beyond to document nearly every aspect of a surgery. And though it's unrealistic to expect every surgery to be fully documented, there are few ways to make the process more palatable. Here are a few things to consider:
- PLAN: There is much that can be done on the front end through scheduling. Knowing that surgeries will overlap ahead of time will give hospital staff the ability to plan accordingly.
- DOCUMENT: The more that is documented,
the safer a hospital is overall. Some important things to keep note
- The surgeon was present for the "critical" parts of a surgery, having already defined what those critical parts are.
- The surgeon was "immediately available" via a paging system, as well as any other mandates put forth by the hospital.
- Identification of the replacing surgeon who will spell the initial surgeon if he or she has to leave to tend to another surgery.
- Every individual in the room, including surgeons, nurses, anesthesiologists, etc., with time stamps of when they entered and when they left.4
- FOLLOW UP: In the fast-paced environment of a hospital, following up with other employees is an excellent way to make sure everyone is aligned and that documentation is as robust as possible. This process should be established through the hospital's policies on overlapping surgery.
Developing a Policy
Developing policies to address the practice of overlapping surgeries is an important first step in helping to ensure that such surgeries are safe and are not, in fact, concurrent. Additionally, staff training should ensure that all persons, from administrators to training fellows, understand the policies and oversight of those policies.
The SFC was encouraged when roughly a third of the hospitals contacted had plans to conduct audits to help ensure staff compliance with policies,5 and some even encouraged anesthesiologists to cancel surgeries if practices were being violated.6 The SFC would like to see more of these proactive policies put in place. Below are paraphrased policies from the hospitals surveyed whose specific language on the topic of overlapping and concurrent surgeries should act as a guiding step in the right direction:
- Hospitals should conduct quarterly or random audits of adherence to the overlapping policy and/or of the performance of surgeons performing overlapping operations.
- Hospitals should conduct audits or monitor reports of overlapping surgeries to ensure compliance with CMS's billing requirements for teaching physicians.
- Staff should report observed violations of the overlapping surgical policy.
- Violations of the overlapping surgical policy could result in the loss of a surgeon's overlapping surgical privileges.7
A Safe Option
For now, it may seem that the practice of overlapping surgeries is in the crosshairs of the SFC. However, overlapping surgeries remain a safe option for patients and a profitable practice for hospitals, so long as they are properly documented.
Thus, hospital administrators must determine if their practices are consistent with the CMS's revised guidance, using the ACS guidance as a useful reference. If not, CMS officials will act. The Joint Commission, a CMS-certified organization, has started citing hospitals for surgical infractions and are carefully scrutinizing hospital policies to ensure that they are following the proposed guidelines.
2 ibid., 19.
3 ibid., 13.
4 ibid., 14.
5 ibid., 15.
CMS, Medicare Claims Processing Manual: Chapter 12 – Physicians/Nonphysician Practitioners (revised March 2016); CMS, State Operations Manual: Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (revised November 2015); and American College of Surgeons, Statements on Principles (revised April 12, 2016).
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