Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

TO:      All Providers Participating in MassHealth FROM:      Douglas S. Brown, Acting Commissioner RE:      All Provider Manuals (Revised Regulations)

MASSHEALTH
TRANSMITTAL LETTER ALL-119
October 2003

This letter transmits revised regulations to reflect that the Primary Care Clinician (PCC) Plan no longer distinguishes between outpatient department PCCs with or without restricted enrollment when applying the physical-presence rules set forth in 130 CMR 450.000.
These regulations are effective October 1, 2003.
NEW MATERIAL
(The pages listed here contain new or revised language.)
All Provider Manuals
Pages 2-35 and 2-36
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
All Provider Manuals
Pages 2-35 and 2-36 — transmitted by Transmittal Letter ALL-113

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
2-35	

	TRANSMITTAL LETTER
ALL-119	DATE
10/01/03	
(D) Covered Services. The Division pays for medical services (including, but not limited to, evaluation and management services, surgery services, anesthesia services, and radiology services) performed in a teaching setting if the following requirements are met, in addition to the general requirements in 130 CMR 450.275(A) through (C):
 (1)	Exceptions to Physical-Presence Requirement. For certain services (general/internal medicine, pediatric, obstetric/gynecologic, and psychiatric), the teaching physician does not have to be physically present for the key portions of the service. (Refer to Appendix K of the Physician Manual for a listing of the service codes for which this exception to the physical presence requirement applies.)
 (2)	Services Paid on the Basis of Time. For services paid on the basis of time (excluding anesthesia and those psychiatric services listed in Appendix K of the Physician Manual), the teaching physician must be present for the period of time for which the claim is made. Time spent by the resident in the absence of the teaching physician may not be added to time spent by the resident and teaching physician with the member, or time spent by the teaching physician alone with the member. For example, the Division pays for a code that specifically describes a service of from 20 to 30 minutes only if the teaching physician is present for 20 to 30 minutes.
 (3)	Medical Services. For medical services (including, but not limited to, evaluation and management services), the teaching physician may supervise up to four residents at any given time, and he or she must direct the care from such proximity as to constitute immediate physical availability.
 (4)	Surgery Services. For surgery services, the teaching physician is responsible for the preoperative, intra-operative, and postoperative care of the member. The teaching physician must be scrubbed and physically present during the key portion of the surgical procedure. During the intra-operative period in which the teaching physician is not physically present, he or she must remain immediately available to return to the procedure, if necessary. He or she must not be involved in another procedure from which he or she cannot return. If the teaching physician leaves the operating room after the key portions of the surgical procedure or during the closing of the surgical site to become involved in another surgical procedure, he or she must arrange for another teaching physician to be immediately available to intervene as needed. The designee must be a physician (excluding a resident) who is not involved in or immediately available for any other surgical procedure. The following guidelines apply to specific types of surgery and related services:

 (a)	Concurrent Surgeries. To be paid for concurrent surgeries, the teaching physician must be present during the key portions of both operations. Therefore, the key portions must not occur simultaneously. When all of the key portions of the first procedure have been completed, the teaching physician may initiate his or her involvement in a second procedure. The teaching physician must personally document the key portions of both procedures in his or her notes to demonstrate that he or she was immediately available to return to either procedure as needed.
 (b)	Straightforward or Low-complexity Procedures. The teaching physician must be present for the decision-making portions of straightforward or low-complexity procedures.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
2-36	

	TRANSMITTAL LETTER
ALL-119	DATE
10/01/03	
 (c)	Endoscopy Procedures. For procedures performed through an endoscope (other than endoscopic operations, when the endoscopy performed is not the key portion of the surgical procedure), the teaching physician must be present during the entire viewing. The entire viewing includes the period of insertion through removal of the device. Viewing of the entire procedure through a monitor in another room does not meet the teaching-physician-presence requirement.
 (d)	Obstetrics. To be paid for the procedure, the teaching physician must be present for the delivery. In situations in which the teaching physician's only involvement was at the time of delivery, he or she may bill for the delivery only. To be paid for the global procedures, the teaching physician must be physically present, in accordance with the general requirements above and applicable program requirements.

 (5)	Anesthesia Services. If a teaching anesthesiologist is involved in a procedure with a resident, or with a resident and a non-physician anesthetist, the teaching physician must be present for induction and emergence. For any other portion of the anesthesia service, the teaching physician must be immediately, physically available to return to the procedure, as needed. The documentation in the medical records must indicate the teaching anesthesiologist’s presence and participation in the administration of the anesthesia.
 (6)	Radiology Services. The interpretation of diagnostic tests must be performed or reviewed by a teaching physician. If the teaching physician’s signature is the only signature on the interpretation, this indicates that he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed both the image and the resident’s interpretation and either agrees with or edits the findings. The teaching physician’s countersignature alone is not acceptable documentation.
(130 CMR 450.276 through 450.300 Reserved)