AANS Neurosurgeon | Volume 28, Number 4, 2019


When Running One Operating Room Just is Not Enough

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The appropriateness of running multiple simultaneous operating rooms is a controversial topic that has been in the spotlight recently. While there are powerful arguments to support both sides of this debate, our focus today is on coding and documentation under the circumstances. This is a non-issue for the majority of neurosurgical practices, but for busy academic training centers and centers focused on resident or fellowship training, this is common practice.

Setting the Stage
You get that phone call from your chief resident that there has been a bus accident and there are two patients with operative subdural hematomas being intubated in the level 1 trauma center you are covering. As you race in, you asked the chief resident to get started with one, while the junior resident (not intern) moves the other along, simultaneously. Your plan is to save both patients by running simultaneous rooms in order to prevent any unnecessary delay in treatment. As you walk into the OR, your chief resident is about to make a skin incision and the junior has just begun prepping. You review the cases and films and call for timeout in each room. You scrub in with your junior resident and take him or her through the case, as the chief is working next door. When you finish with the critical portions of the case, you leave the junior to close, and go next door to supervise the chief resident as he or she is beginning the critical components of his or her case. When the dust settles, we are left with the following:

1. Two emergency craniotomies performed simultaneously.
2. The attending of record performed timeout in both rooms.
3. The attending of record was present for the critical portions of each case.
4. Resident assistance was used in both cases.

So what does Medicare say about such a situation? In order to bill Medicare for two overlapping surgeries, the teaching neurosurgeon must be present during the critical or key portions of both operations. Therefore, the critical or key portions may not take place at the same time. We see that in this situation, the critical portions, as we define them, were staggered, and thus, this is allowable. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. The teaching surgeon must personally document in the medical record that he or she was physically present during the critical or key portions of both procedures. Therefore, the operative dictation will be absolutely critical in this situation. It needs to be made clear that the surgeries were emergencies and that the above-mentioned factors are reflected clearly in the medical record. 

Another issue that becomes important is the experience of the assistant. Many of these rules apply to residents with more than six months in a Graduate Medical Education (GME)-approved residency program. If the resident does not meet these criteria, then the teaching physician may not have responsibilities other than the supervision of that particular junior resident. We will assume for this situation that this is not the case as it is not realistic for an intern to be independently covering overnight call at a level I trauma center.

How to Code
As far as the coding goes, there is a little to differentiate parallel procedures from procedures performed in a series. We would use craniotomy for subdural hematoma 61312 and simply add modifiers for resident involvement 61312–GC. Other than this, there is nothing in the CPT coding that would differentiate the cases performed in a series versus in parallel with another case.

In summary, running parallel cases is common practice in academic settings and may be unavoidable in class A emergencies, where the patient must be in the operating room within a 45-minute timeframe.  In such cases, documentation, in particular the operative report, must be detailed and precise. There is little change in CPT coding as long as proper protocol is followed, other than the resident modifier. If your situation does not quite match the idealized situation above, do not bill for the second case.

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