C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 415—SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS › Subpart D—Physician Services in Teaching Settings

42 C.F.R. § 415.172

Physician fee schedule payment for services of teaching physicians

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(a) General rule. If a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought. In residency training sites that are located outside a metropolitan statistical area, physician fee schedule payment may also be made if a teaching physician is present during the key portion of the service, including for Medicare telehealth services, through audio/video real-time communications technology for any service or procedure for which payment is sought. For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, if a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made if a teaching physician is present during the key portion of the service including for Medicare telehealth services, through audio/video real-time communications technology for any service or procedure for which payment is sought.

(1) In the case of surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical portions of the procedure and immediately available to furnish services during the entire service or procedure.

(i) In the case of surgery, the teaching physician's presence is not required during opening and closing of the surgical field.

(ii) In the case of procedures performed through an endoscope, the teaching physician must be present during the entire viewing.

(2) In the case of evaluation and management services, except as otherwise provided in this paragraph (a)(2), the teaching physician must be present in person during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of § 415.174 apply.)

(i) In residency training sites that are located outside of a metropolitan statistical area, the teaching physician may be present through audio/video real-time communications technology during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of § 415.174 apply.)

(ii) For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, the teaching physician may be present through audio/video real-time communications technology during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of § 415.174 apply.)

(b) Documentation. Except as otherwise provided in this paragraph (b), except for services furnished as set forth in §§ 415.174 (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), §§ 415.176 (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document that the teaching physician was present at the time the service (including a Medicare telehealth service) is furnished. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in § 410.20(e) of this chapter.

(1) In residency training sites that are located outside of a metropolitan statistical area only, except for services furnished as set forth in §§ 415.174 (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), 415.176 (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document whether the teaching physician was physically present or present through audio/video real-time communications technology at the time the service (including a Medicare telehealth service) is furnished. The medical records must contain a notation describing the specific portion(s) of the service for which the teaching physician was present through audio/video real-time communications technology. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in § 410.20(e) of this chapter.

(2) For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, except for services furnished as set forth in §§ 415.174 (concerning an exception for services furnished in hospital outpatient and certain other ambulatory settings), 415.176 (concerning renal dialysis services), and 415.184 (concerning psychiatric services), the medical records must document whether the teaching physician was physically present or present through audio/video real-time communications technology at the time the service (including a Medicare telehealth service) is furnished. The medical records must contain a notation describing the specific portion(s) of the service for which the teaching physician was present through audio/video real-time communications technology. The presence of the teaching physician during procedures and evaluation and management services may be demonstrated by the notes in the medical records made by the physician or as provided in § 410.20(e) of this chapter.

(c) Payment level. In the case of services such as evaluation and management for which there are several levels of service codes available for reporting purposes, the appropriate payment level must reflect the extent and complexity of the service when fully furnished by the teaching physician.

[60 FR 63178, Dec. 8, 1995, as amended at 83 FR 60091, Nov. 23, 2018; 84 FR 63201, Nov. 15, 2019; 85 FR 19288, Apr. 6, 2020; 85 FR 27623, May 8, 2020; 85 FR 85036, Dec. 28, 2020]
Notes of Decisions
Cited in 17 cases (2 in the last 5 years), 1998–2025 · leading case: Goldberg v. Rush Univ. Med. Ctr., 929 F. Supp. 2d 807 (N.D. Ill. 2013).
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Goldberg v. Rush Univ. Med. Ctr., 929 F. Supp. 2d 807 (N.D. Ill. 2013). · cites it 5× “Background Relators rely upon three sets of rules and regulations pertaining to overlapping surgeries: (1) the Medicare regulation entitled “Physician fee schedule payment for services of teaching physicians” (“Teaching Physician Regulations”), 42 C.F.R. § 415.172 ; (2)…”
United States Ex Rel. Smith v. Yale Univ., 415 F. Supp. 2d 58 (D. Conn. 2006). · cites it 3× “42 C.F.R. 415.172. Accordingly, the form that physicians must submit to Medicare and Medicaid in order to be entitled to reimbursement includes the following certification: “Signature of Physician or Supplier: I certify that the services shown on *64 this form were medically…”
United States Ex Rel. Mateski v. Raytheon Co., 816 F.3d 565 (9th Cir. 2016). “(quoting 42 C.F.R. § 415.172 (a)(1)). The Seventh Circuit concluded in Goldberg that “[relators] allege a kind of deceit that the GAO report does not attribute to any- teaching hospital,” and that the public disclosure bar therefore did not apply.”
The Univ. of Texas Sw. Med. Ctr. at Dallas v. Larry M. Gentilello, M.D., 398 S.W.3d 680 (Tex. 2013). “(citing 42 C.F.R. §§ 415.172 , 482.11, 482.12(a), and 482.”
Univ. of Texas Sw. Med. Ctr. at Dallas v. Gentilello, 317 S.W.3d 865 (Tex. App. 2010). · cites it 2× “42 C.F.R. § 415.172 . If emergency services are provided, the hospital must meet emergency needs in accordance with acceptable standards.”
United States Ex Rel. Goldberg v. Rush Univ. Med. Ctr., 680 F.3d 933 (7th Cir. 2012). “” 42 C.F.R. § 415.172 (a)(1). The complaint alleges that Rush scheduled teaching physicians for multiple surgeries simultaneously, so that even if the teaching physician were present for the “critical” portion of one (indeed, for all “critical” portions of all surgeries in a…”
US Ex Rel. Schuhardt v. Washington Univ., 228 F. Supp. 2d 1018 (E.D. Mo. 2002). · cites it 2× “Furthermore, 42 C.F.R. § 415.172 states: (a) General rule.”
Cong. of California Seniors v. Catholic Healthcare West, 2001 Cal. Daily Op. Serv. 1713 (Cal. Ct. App. 2001). “59-60; 42 C.F.R.415.172.) There are different cost reporting requirements for (among others) proprietary facilities (42 U.”
United States ex rel. Holloway v. Heartland Hospice, Inc., 386 F. Supp. 3d 884 (N.D. Ohio 2019). “3d at 935 (quoting 42 C.F.R. § 415.172 (a)(1) ) (internal quotations omitted).”
Ass'n of Am. Med. Colleges v. United States, 34 F. Supp. 2d 1187 (C.D. Cal. 1998). · cites it 2× “42 C.F.R. § 415.172 et seq. (the “1996 regulations”).”
US EX REL. SCHUHARDT v. Washington Univ., 361 F. Supp. 2d 992 (E.D. Mo. 2003). · cites it 2× “For the period after July 1, 1996 42 C.F.R. § 415.172 (b) provides that: the medical records must document the teaching physician was present at the time the service was furnished.”
Wollman v. Massachusetts Gen. Hosp. Inc. (D. Mass. 2019). · cites it 5× “” 42 C.F.R. § 415.172 (a)(1); SAC ¶ 44. When conducting overlapping surgeries, only once “all of the key portions of the initial procedure have been completed” may the teaching physician “begin to become involved in a second procedure.”
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