PART 415—SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Authority: 42 U.S.C. 1302 and 1395hh. Source: 60 FR 63178, Dec. 8, 1995, unless otherwise noted. Subpart A—General Provisions § 415.1 Basis and scope. (a) Basis. (b) Scope. Subpart B—Fiscal Intermediary Payments to Providers for Physician Services § 415.50 Scope. This subpart sets forth rules for payment by fiscal intermediaries to providers for services furnished by physicians. Payment for covered services is made either under the prospective payment system (PPS) to PPS-participating providers in accordance with part 412 of this chapter or under the reasonable cost method to non-PPS participating providers in accordance with part 413 of this chapter. § 415.55 General payment rules. (a) Allowable costs. (1) The services do not meet the conditions in § 415.102(a) regarding fee schedule payment for services of physicians to a beneficiary in a provider. (2) The services include a surgeon's supervision of services of a qualified anesthetist, but do not include physician availability services, except for reasonable availability services furnished for emergency rooms and the services of standby surgical team physicians. (3) The provider has incurred a cost for salary or other compensation it furnished the physician for the services. (4) The costs incurred by the provider for the services meet the requirements in § 413.9 of this chapter regarding costs related to patient care. (5) The costs do not include supervision of interns and residents unless the provider elects reasonable cost payment as specified in § 415.160, or any other costs incurred in connection with an approved GME program that are payable under §§ 413.75 through 413.83 of this chapter. (b) Allocation of allowable costs. (c) Limits on allowable costs. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.60 Allocation of physician compensation costs. (a) Definition. physician compensation costs (b) General rule. (1) Physician services to the provider (as described in § 415.55); (2) Physician services to patients (as described in § 415.102); and (3) Activities of the physician, such as funded research, that are not paid under either Part A or Part B of Medicare. (c) Allowable physician compensation costs. (d) Allocation of all compensation to services to the provider. (1) The provider certifies that the compensation is attributable solely to the physician services furnished to the provider; and (2) The physician bills all patients for the physician services he or she furnishes to them and personally receives the payment from or on behalf of the patients. If returned directly or indirectly to the provider or an organization related to the provider within the meaning of § 413.17 of this chapter, these payments are not compensation for physician services furnished to the provider. (e) Assumed allocation of all compensation to beneficiary services. (f) Determination and payment of allowable physician compensation costs. (i) The provider submits to the intermediary a written allocation agreement between the provider and the physician that specifies the respective amounts of time the physician spends in furnishing physician services to the provider, physician services to patients, and services that are not payable under either Part A or Part B of Medicare; and (ii) The compensation is reasonable in terms of the time devoted to these services. (2) In the absence of a written allocation agreement, the intermediary assumes, for purposes of determining reasonable costs of the provider, that 100 percent of the physician compensation cost is allocated to services to beneficiaries as specified in paragraph (b)(2) of this section. (g) Recordkeeping requirements. (1) Maintain the time records or other information it used to allocate physician compensation in a form that permits the information to be validated by the intermediary or the carrier. (2) Report the information on which the physician compensation allocation is based to the intermediary or the carrier on an annual basis and promptly notify the intermediary or carrier of any revisions to the compensation allocation. (3) Retain each physician compensation allocation, and the information on which it is based, for at least 4 years after the end of each cost reporting period to which the allocation applies. § 415.70 Limits on compensation for physician services in providers. (a) Principle and scope. (2) Limits established under this section do not apply to costs of physician compensation attributable to furnishing inpatient hospital services that are paid for under the prospective payment system implemented under part 412 of this chapter or to costs of physician compensation attributable to approved GME programs that are payable under §§ 413.75 through 413.83 of this chapter. (3) Compensation that a physician receives for activities that may not be paid for under either Part A or Part B of Medicare is not considered in applying these limits. (b) Methodology for establishing limits. For cost reporting periods beginning before January 1, 2015. (2) For cost reporting periods beginning on or after January 1, 2015. (c) Application of limits. (d) Adjustment of the limits. (1) For the costs of membership in professional societies and continuing medical education, the intermediary may adjust the limit by the lesser of— (i) The actual cost incurred by the provider or the physician for these activities; or (ii) Five percent of the appropriate limit. (2) For the cost of malpractice expenses incurred by either the provider or the physician, the intermediary may adjust the reasonable compensation equivalency limit by the cost of the malpractice insurance expense related to the physician service furnished to patients in providers. (e) Exception to limits. (f) Notification of changes in methodologies and payment limits. Federal Register (2) If CMS proposes to revise the methodology for establishing payment limits under this section, CMS publishes a notice, with opportunity for public comment, in the Federal Register. (3) If CMS updates limits by applying the most recent economic index data without revising the limit methodology, CMS publishes the revised limits in a notice in the Federal Register [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005; 79 FR 50358, Aug. 22, 2014] Subpart C—Part B Carrier Payments for Physician Services to Beneficiaries in Providers § 415.100 Scope. This subpart implements section 1887(a)(1)(A) of the Act by providing general conditions that must be met in order for services furnished by physicians to beneficiaries in providers to be paid for on the basis of the physician fee schedule under part 414 of this chapter. Section 415.102 sets forth the conditions for fee schedule payment for physician services to beneficiaries in providers. Section 415.105 sets forth general requirements for determining the amounts of payment for services that meet the conditions of this section. Sections 415.120 and 415.130 set forth additional conditions for payment for physician services in the specialties of radiology and pathology (laboratory services). § 415.102 Conditions for fee schedule payment for physician services to beneficiaries in providers. (a) General rule. (1) The services are personally furnished for an individual beneficiary by a physician. (2) The services contribute directly to the diagnosis or treatment of an individual beneficiary. (3) The services ordinarily require performance by a physician. (4) In the case of radiology or laboratory services, the additional requirements in § 415.120 or § 415.130, respectively, are met. (b) Exception. (c) Effect of billing charges for physician services to a provider. (2) If a physician furnishes services to an individual beneficiary that do not meet the applicable conditions in §§ 415.120 (concerning conditions for payment for radiology services) and 415.130 (concerning conditions for payment for physician pathology services), the carrier does not pay on a fee schedule basis. (3) If the physician, the provider, or another entity bills the carrier or the beneficiary or another insurer for physician services furnished to the provider, as described in § 415.55(a), CMS considers the provider to which the services are furnished to have violated its provider participation agreement, and may terminate that agreement. See part 489 of this chapter for rules governing provider agreements. (d) Effect of physician assumption of operating costs. (1) If the conditions set forth in paragraph (a) of this section are met, the carrier pays for the physician services under the physician fee schedule in part 414 of this chapter. (2) To the extent the provider incurs a cost payable on a reasonable cost basis under part 413 of this chapter, the intermediary pays the provider on a reasonable cost basis for the costs associated with producing these services, including overhead, supplies, equipment costs, and services furnished by nonphysician personnel. (3) The physician (or other entity) is treated as being related to the provider within the meaning of § 413.17 of this chapter (concerning cost to related organizations). (4) The physician (or other entity) must make its books and records available to the provider and the intermediary as necessary to verify the nature and extent of the costs of the services furnished by the physician (or other entity). [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.105 Amounts of payment for physician services to beneficiaries in providers. (a) General rule. (b) Application in certain settings Teaching hospitals. (2) Hospital-based ESRD facilities. § 415.110 Conditions for payment: Medically directed anesthesia services. (a) General payment rule. (1) For each patient, the physician— (i) Performs a pre-anesthetic examination and evaluation; (ii) Prescribes the anesthesia plan; (iii) Personally participates in the most demanding aspects of the anesthesia plan including, if applicable, induction and emergence; (iv) Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual as defined in operating instructions; (v) Monitors the course of anesthesia administration at frequent intervals; (vi) Remains physically present and available for immediate diagnosis and treatment of emergencies; and (vii) Provides indicated post-anesthesia care. (2) The physician directs no more than four anesthesia services concurrently and does not perform any other services while he or she is directing the single or concurrent services so that one or more of the conditions in paragraph (a)(1) of this section are not violated. (3) If the physician personally performs the anesthesia service, the payment rules in § 414.46(c) of this chapter apply (Physician personally performs the anesthesia procedure). (b) Medical documentation. [63 FR 58912, Nov. 2, 1998] § 415.120 Conditions for payment: Radiology services. (a) Services to beneficiaries. (b) Services to providers. § 415.130 Conditions for payment: Physician pathology services. (a) Definitions. (1) Covered hospital (2) Fee-for-service Medicare beneficiaries (i) A Medicare + Choice plan under Part C of Title XVIII of the Act. (ii) A plan offered by an eligible organization under section 1876 of the Act; (iii) A program of all-inclusive care for the elderly (PACE) under 1894 of the Act; or (iv) A social health maintenance organization (SHMO) demonstration project established under section 4018(b) of the Omnibus Budget Reconciliation Act of 1987. (b) Physician pathology services. (1) Surgical pathology services. (2) Specific cytopathology, hematology, and blood banking services that have been identified to require performance by a physician and are listed in program operating instructions. (3) Clinical consultation services that meet the requirements in paragraph (c) of this section. (4) Clinical laboratory interpretative services that meet the requirements of paragraphs (c)(1), (c)(3), and (c)(4) of this section and that are specifically listed in program operating instructions. (c) Clinical consultation services. (1) Be requested by the beneficiary's attending physician. (2) Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the beneficiary. (3) Result in a written narrative report included in the beneficiary's medical record. (4) Require the exercise of medical judgment by the consultant physician. (d) Physician pathology services furnished by an independent laboratory. (2) For services furnished after June 30, 2012, an independent laboratory may not bill the Medicare contractor for the technical component of physician pathology services furnished to a hospital inpatient or outpatient. (3) For services furnished on or after January 1, 2008, the date of service policy in § 414.510 of this chapter applies to the TC of specimens for physician pathology services. [60 FR 63178, Dec. 8, 1995, as amended at 64 FR 59442, Nov. 2, 1999; 66 FR 55332, Nov. 1, 2001; 71 FR 69788, Dec. 1, 2006; 72 FR 66405, Nov. 27, 2007; 73 FR 69938, Nov. 19, 2008; 75 FR 73626, Nov. 29, 2010; 76 FR 73473, Nov. 28, 2011; 77 FR 69371, Nov. 16, 2012] § 415.140 Conditions for payment: Split (or shared) visits. (a) Definitions. Facility setting Split (or shared) visit Substantive portion (b) Conditions of payment. (1) Substantive portion of split (or shared) visit. (2) Medical record documentation. (3) Claim modifier. [86 FR 65682, Nov. 19, 2021, as amended at 87 FR 70230, Nov. 18, 2022; 88 FR 79539, Nov. 16, 2023] Subpart D—Physician Services in Teaching Settings § 415.150 Scope. This subpart sets forth the rules governing payment for the services of physicians in teaching settings and the criteria for determining whether the payments are made as one of the following: (a) Services to the hospital under the reasonable cost election in §§ 415.160 through 415.164. (b) Provider services through the direct GME payment mechanism in §§ 413.75 through 413.83 of this chapter. (c) Physician services to beneficiaries under the physician fee schedule as set forth in part 414 of this chapter. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.152 Definitions. Link to an amendment published at 91 FR 50346, Aug. 4, 2026. As used in this subpart— Approved graduate medical education (GME) program (1) A residency program approved by the Accreditation Council for Graduate Medical Education, by the American Osteopathic Association, by the Commission on Dental Accreditation of the American Dental Association, or by the Council on Podiatric Medical Education of the American Podiatric Medical Association, or other organization determined by the Secretary, provided that the applicable organization does not use accreditation criteria that promote or encourage discrimination on the basis of race, color, national origin, sex, age, disability, or religion, including the use of those characteristics or intentional proxies for those characteristics as a selection criterion for employment, program participation, resource allocation, or similar activities, opportunities, or benefits. (2) A program otherwise recognized as an “approved medical residency program” under § 413.75(b) of this chapter. Direct medical and surgical services Nonprovider setting Resident (1) An individual who participates in an approved GME program, including programs in osteopathy, dentistry, and podiatry. (2) A physician who is not in an approved GME program, but who is authorized to practice only in a hospital, for example, individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools. For purposes of this subpart, the term resident intern fellow. Teaching hospital Teaching physician Teaching setting [60 FR 63178, Dec. 8, 1995, as amended at 61 FR 59554, Nov. 22, 1996; 63 FR 26359, May 12, 1998; 70 FR 47490, Aug. 12, 2005; 74 FR 44001, Aug. 27, 2009; 75 FR 50418, Aug. 16, 2010; 90
FR 54084, Nov. 25, 2025] § 415.160 Election of reasonable cost payment for direct medical and surgical services of physicians in teaching hospitals: General provisions. (a) Scope. (b) Conditions. (1) The hospital notifies its intermediary in writing of the election and meets the conditions of either paragraph (b)(2) or paragraph (b)(3) of this section; (2) All physicians who furnish services to Medicare beneficiaries in the hospital agree not to bill charges for these services; or (3) All physicians who furnish services to Medicare beneficiaries in the hospital are employees of the hospital and, as a condition of employment, are precluded from billing for these services. (c) Effect of election. (1) Those services and the supervision of interns and residents furnishing care to individual beneficiaries are covered as hospital services, and (2) The intermediary pays the hospital for those services on a reasonable cost basis under the rules in § 415.162. (Payment for other physician compensation costs related to approved GME programs is made as described in § 413.78 of this chapter.) (d) Election declined. (1) For physician services furnished to beneficiaries on a fee schedule basis as described in part 414 subject to the rules in this subpart, and (2) For the supervision of interns and residents as described in §§ 413.75 through 413.83. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.162 Determining payment for physician services furnished to beneficiaries in teaching hospitals. (a) General rule. (1) Physician services furnished to beneficiaries and supervision of interns and residents furnishing care to beneficiaries are paid on a reasonable-cost basis, as provided for in paragraph (b) of this section. (2) Payment for certain medical school costs may be made as provided for in paragraph (c) of this section. (3) Payments for services donated by volunteer physicians to beneficiaries are made to a fund designated by the organized medical staff of the teaching hospital or medical school as provided for in paragraph (d) of this section. (b) Reasonable cost of physician services and supervision of interns and residents. (2) For purposes of this paragraph, reasonable cost (3) The costs must be allocated to the services as provided by paragraph (j) of this section and apportioned to program beneficiaries as provided by paragraph (g) of this section. (4) Other allowable costs incurred by the provider related to the services described in this paragraph are payable subject to the requirements applicable to all other provider services. (c) Reasonable costs for the services furnished by a medical school or related organization in a hospital. (1) Reasonable costs of physician services When the medical school and the hospital are related organizations. (A) The costs of these services are allowable costs to the hospital under the provisions of § 413.17 of this chapter; and (B) The reimbursable costs to the hospital are determined under the provisions of this section in the same manner as the costs incurred for physicians on the hospital staff and without regard to payments made to the medical school by the hospital. (ii) When the medical school and the hospital are not related organizations. (B) Costs incurred under an arrangement must be allocated to the full range of services furnished to the hospital by the medical school physicians on the same basis as provided for under paragraph (j) of this section, and costs allocated to direct medical and surgical services furnished to hospital patients must be apportioned to beneficiaries as provided for under paragraph (g) of this section. (C) If the medical school and the hospital are not related organizations under the provisions of § 413.17 of this chapter and the hospital makes payment to the medical school only for the costs of those services furnished to beneficiaries, costs of the medical school not to exceed 105 percent of the sum of physician direct salaries, applicable fringe benefits, employer's portion of FICA taxes, Federal and State unemployment taxes, and workmen's compensation paid by the medical school or an organization related to the medical school may be recognized as allowable costs of the medical school. (D) These allowable medical school costs must be allocated to the full range of services furnished by the physicians of the medical school or organization related as provided by paragraph (j) of this section. (E) Costs allocated to direct medical and surgical services furnished to hospital patients must be apportioned to beneficiaries as provided by paragraph (g) of this section. (2) Reasonable costs of other than direct medical and surgical services. (i) If the hospital makes payment to the medical school for other than direct medical and surgical services furnished to beneficiaries and supervision of interns and residents furnishing care to beneficiaries, these payments are subject to the required cost-finding and apportionment methods applicable to the cost of other hospital services (except for direct medical and surgical services furnished to beneficiaries); or (ii) If the hospital makes payment to the medical school only for these services furnished to beneficiaries, the cost of these services is not subject to cost-finding and apportionment as otherwise provided by this subpart, and the reasonable cost paid by Medicare must be determined on the basis of the health insurance ratio(s) used in the apportionment of all other provider costs (excluding physician direct medical and surgical services furnished to beneficiaries) applied to the allowable medical school costs incurred by the medical school for the services furnished to all patients of the hospital. (d) “Salary equivalent” payments for direct medical and surgical services furnished by physicians on the voluntary staff of the hospital. (i) These payments represent compensation for contributed medical staff time which, if not contributed, would have to be obtained through employed staff on a payable basis. (ii) Payments for volunteer services are determined by applying to the regularly scheduled contributed time an hourly rate not to exceed the equivalent of the average direct salary (exclusive of fringe benefits) paid to all full-time, salaried physicians (other than interns and residents) on the hospital staff or, if the number of full-time salaried physicians is minimal in absolute terms or in relation to the number of physicians on the voluntary staff, to physicians at like institutions in the area. (iii) This “salary equivalent” is a single hourly rate covering all physicians regardless of specialty and is applied to the actual regularly scheduled time contributed by the physicians in furnishing direct medical and surgical services to beneficiaries including supervision of interns and residents in that care. (iv) A physician who receives any compensation from the hospital or a medical school related to the hospital by common ownership or control (within the meaning of § 413.17 of this chapter) for direct medical and surgical services furnished to any patient in the hospital is not considered an unpaid voluntary physician for purposes of this paragraph. (v) If, however, a physician receives compensation from the hospital or related medical school or organization only for services that are other than direct medical and surgical services, a salary equivalent payment for the physician's regularly scheduled direct medical and surgical services to beneficiaries in the hospital may be imputed. However, the sum of the imputed value for volunteer services and the physician's actual compensation from the hospital and the related medical school (or organization) may not exceed the amount that would have been imputed if all of the physician's hospital and medical school services (compensated and volunteer) had been volunteer services, or paid at the rate of $30,000 per year, whichever is less. (2) The following examples illustrate how the allowable imputed value for volunteer services is determined. In each example, it has been assumed that the average salary equivalent hourly rate is equal to the hourly rate for the individual physician's compensated services. Example No: 1. Dr. Jones received $3,000 a year from Hospital X for services other than direct medical services to all patients, for example, utilization review and administrative services. Dr. Jones also voluntarily furnished direct medical services to beneficiaries. The imputed value of the volunteer services amounted to $10,000 for the cost reporting period. The full imputed value of Dr. Jones' volunteer direct medical services would be allowed since the total amount of the imputed value ($10,000) and the compensated services ($3,000) does not exceed $30,000. Example No: 2. Dr. Smith received $25,000 from Hospital X for services as a department head in a teaching hospital. Dr. Smith also voluntarily furnished direct medical services to beneficiaries. The imputed value of the volunteer services amounted to $10,000. Only $5,000 of the imputed value of volunteer services would be allowed since the total amount of the imputed value ($10,000) and the compensated services ($25,000) exceeds the $30,000 maximum amount allowable for all of Dr. Smith's services. Computation: Maximum amount allowable for all services performed by Dr. Smith for purposes of this computation $30,000 Less compensation received from Hospital X for other than direct medical services to individual patients $25,000 Allowable amount of imputed value for the volunteer services furnished by Dr. Smith $5,000 Example No. 3. Dr. Brown is not compensated by Hospital X for any services furnished in the hospital. Dr. Brown voluntarily furnished direct surgical services to beneficiaries for a period of 6 months, and the imputed value of these services amounted to $20,000. The allowable amount of the imputed value for volunteer services furnished by Dr. Brown would be limited to $15,000 ($30,000 × 6/12). (3) The amount of the imputed value for volunteer services applicable to beneficiaries and payable to a fund is determined in accordance with the aggregate per diem method described in paragraph (g) of this section. (4) Medicare payments to a fund must be used by the fund solely for improvement of care of hospital patients or for educational or charitable purposes (which may include but are not limited to medical and other scientific research). (i) No personal financial gain, either direct or indirect, from benefits of the fund may inure to any of the hospital staff physicians, medical school faculty, or physicians for whom Medicare imputes costs for purposes of payment into the fund. (ii) Expenses met from contributions made to the hospital from a fund are not included as a reimbursable cost when expended by the hospital, and depreciation expense is not allowed with respect to equipment or facilities donated to the hospital by a fund or purchased by the hospital from monies in a fund. (e) Requirements for payment Physicians on the hospital staff. (2) Physicians on the medical school faculty. (i) There is a written agreement between the hospital and the medical school or organization, specifying the types and extent of services to be furnished by the medical school and specifying that the hospital must pay to the medical school an amount at least equal to the reasonable cost (as defined in paragraph (c) of this section) of furnishing the services to beneficiaries. (ii) The costs are paid to the medical school by the hospital no later than the date on which the cost report covering the period in which the services were furnished is due to CMS. (iii) Payment for the services furnished under an arrangement would have been made to the hospital had the services been furnished directly by the hospital. (3) Physicians on the voluntary staff of the hospital (or medical school under arrangement with the hospital). (f) Requirements for payment for medical school faculty services other than physician direct medical and surgical services. (g) Aggregate per diem methods of apportionment For the costs of physician direct medical and surgical services. (i) Physicians on the hospital staff. (ii) Physicians on the medical school faculty. (2) For the imputed value of physician volunteer direct medical and surgical services. (h) Definitions. Average cost per diem for physician direct medical and surgical services (including supervision of interns and residents) furnished in a teaching hospital to patients in each category of physician services described in paragraph (g)(1) of this section (i) Inpatient days (as defined in paragraph (h)(2) of this section); and (ii) Outpatient visit days (as defined in paragraph (h)(3) of this section). (2) Inpatient days (3) Outpatient visit days (i) Application. Teaching Hospital Y Statistical and financial data: Total inpatient days as defined in paragraph (h)(2) of this section and outpatient visit days as defined in paragraph (h)(3) of this section 75,000 Total inpatient Part A days 20,000 Total inpatient Part B days where Part A coverage is not available 1,000 Total outpatient Part B visit days 5,000 Total cost of direct medical and surgical services furnished to all patients by physicians on the hospital staff as determined in accordance with paragraph (i) of this section $1,500,000 Total cost of direct medical and surgical services furnished to all patients by physicians on the medical school faculty as determined in accordance with paragraph (i) of this section $1,650,000 Computation of cost applicable to program for physicians on the hospital staff: Average cost per diem for direct medical and surgical services to patients by physicians on the hospital staff: $1,500,000 ÷ 75,000 = $20 per diem. Cost of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part A: $20 per diem × 20,000 $400,000 Cost of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part B: $20 per diem × 1,000 $20,000 Cost of physician direct medical and surgical services furnished to outpatient beneficiaries covered under Part B: $20 per diem × 5,000 $100,000 Computation of cost applicable to program for physicians on the medical school faculty: Average cost per diem for direct medical and surgical services to patients by physicians on the medical school faculty: $1,650,000 ÷ 75,000 = $22 per diem. Cost of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part A: $22 per diem × 20,000 $440,000 Cost of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part B: $20 per diem × 1,000 $22,000 Cost of physician direct medical and surgical services furnished to outpatient beneficiaries covered under Part B: $22 per diem × 5,000 $110,000 (2) The following illustrates how the imputed value of physician volunteer direct medical and surgical services furnished in a teaching hospital to beneficiaries is determined. Example: The physicians on the medical staff of Teaching Hospital Y donated a total of 5,000 hours in furnishing direct medical and surgical services to patients of the hospital during a cost reporting period and did not receive any compensation from either the hospital or the medical school. Also, the imputed value for any physician volunteer services did not exceed the rate of $30,000 per year per physician. Statistical and financial data: Total salaries paid to the full-time salaried physicians by the hospital (excluding interns and residents) $800,000 Total physicians who were paid for an average of 40 hours per week or 2,080 (52 weeks × 40 hours per week) hours per year 20 Average hourly rate equivalent: $800,000 ÷ 41,600 (2,080 × 20) $19.23 Computation of total imputed value of physician volunteer services applicable to all patients: (Total donated hours × average hourly rate equivalent): 5,000 × $19.23 $96,150 Total inpatient days (as defined in paragraph (h)(2) of this section) and outpatient visit days (as defined in paragraph (h)(3) of this section) 75,000 Total inpatient Part A days 20,000 Total inpatient Part B days if Part A coverage is not available 1,000 Total outpatient Part B visit days 5,000 Computation of imputed value of physician volunteer direct medical and surgical services furnished to Medicare beneficiaries: Average per diem for physician direct medical and surgical services to all patients: $96,150 ÷ 75,000 = $1.28 per diem Imputed value of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part A: $1.28 per diem × 20,000 $25,600 Imputed value of physician direct medical and surgical services furnished to inpatient beneficiaries covered under Part B: $1.28 per diem × 1,000 $1,280 Imputed value of physician direct medical and surgical services furnished to outpatient beneficiaries covered under Part B: $1.28 per diem × 5,000 $6,400 Total $33,280 (j) Allocation of compensation paid to physicians in a teaching hospital. (2) This allocation must be made and must be capable of substantiation on the basis of the proportion of each physician's time spent in furnishing each type of service to the hospital or medical school. § 415.164 Payment to a fund. (a) General rules. (1) The hospital (or medical school furnishing the services under arrangement with the hospital) incurs no actual cost in furnishing the services. (2) The hospital has an agreement with CMS under part 489 of this chapter. (3) The intermediary, or CMS as appropriate, has received written assurances that— (i) The payment is used solely for the improvement of care of hospital patients or for educational or charitable purposes; and (ii) Neither the individuals who are furnished the services nor any other persons are charged for the services (and if charged, provision is made for the return of any monies incorrectly collected). (b) Definition of a fund. fund (1) The organization has and retains exemption, as a governmental entity or under section 501(c)(3) of the Internal Revenue Code (nonprofit educational, charitable, and similar organizations), from Federal taxation. (2) The organization is an organization of physicians who, under the terms of their employment by an entity that meets the requirements of paragraph (b)(1) of this section, are required to turn over to that entity all income that the physician organization derives from the physician services. (c) Status of a fund. § 415.170 Conditions for payment on a fee schedule basis for physician services in a teaching setting. Services meeting the conditions for payment in § 415.102(a) furnished in teaching settings are payable under the physician fee schedule if— (a) The services are personally furnished by a physician who is not a resident; or (b) The services are furnished by a resident in the presence of a teaching physician except as provided in § 415.172 (concerning physician fee schedule payment for services of teaching physicians), § 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), as applicable. § 415.172 Physician fee schedule payment for services of teaching physicians. (a) General rule. (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. (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. [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] § 415.174 Exception: Evaluation and management services furnished in certain centers. (a) In the case of certain evaluation and management codes of lower and mid-level complexity (as specified by CMS in program instructions), carriers may make physician fee schedule payment for a service furnished by a resident without the presence of a teaching physician. For the exception to apply, all of the following conditions must be met: (1) The services must be furnished in a center that is located in an outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining intermediary payments to a hospital under §§ 413.75 through 413.83. (2) Any resident furnishing the service without the presence of a teaching physician must have completed more than 6 months of an approved residency program. (3) The teaching physician must not direct the care of more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. The teaching physician must— (i) Have no other responsibilities at the time; (ii) Assume management responsibility for those beneficiaries seen by the residents; (iii) Ensure that the services furnished are appropriate; and (iv) Review with each resident during or immediately after each visit, the beneficiary's medical history, physical examination, diagnosis, and record of tests and therapies. (4) The range of services furnished by residents in the center includes all of the following: (i) Acute care for undifferentiated problems or chronic care for ongoing conditions. (ii) Coordination of care furnished by other physicians and providers. (iii) Comprehensive care not limited by organ system, or diagnosis. (5) The patients seen must be an identifiable group of individuals who consider the center to be the continuing source of their health care and in which services are furnished by residents under the medical direction of teaching physicians. (6) The medical records must document the extent of the teaching physician's participation in the review and direction of services furnished to each beneficiary. The extent of the teaching physician's participation may be demonstrated by the notes in the medical records made by the physician or as provided in § 410.20(e) of this chapter to each beneficiary in accordance with the documentation requirements at § 415.172(b). (b) Nothing in paragraph (a) of this section may be construed as providing a basis for the coverage of services not determined to be covered under Medicare, such as routine physical check-ups. (c) For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, the requirements in paragraph (a)(3) of this section for a teaching physician to direct the care and then to review the services furnished by each resident during or immediately after each visit may be met through audio/video real-time communications technology. (d) In residency training sites that are located outside of a metropolitan statistical area only, the requirements in paragraph (a)(3) of this section for a teaching physician to direct the care and then to review the services furnished by each resident during or immediately after each visit may be met through audio/video real-time communications technology. [60 FR 63178, Dec. 8, 1995, as amended at 61 FR 59554, Nov. 22, 1996; 70 FR 47490, Aug. 12, 2005; 83 FR 60092, Nov. 23, 2018; 84 FR 63202, Nov. 15, 2019; 85 FR 19288, Apr. 6, 2020; 85 FR 27624, May 8, 2020; 85 FR 85037, Dec. 28, 2020] § 415.176 Renal dialysis services. In the case of renal dialysis services, physicians who are not paid under the physician monthly capitation payment method (as described in § 414.314 of this chapter) must meet the requirements of §§ 415.170 and 415.172 (concerning physician fee schedule payment for services of teaching physicians). § 415.178 Anesthesia services. (a) General rule. For services furnished prior to January 1, 2010 (2) For services furnished on or after January 1, 2010 (b) Documentation. [74 FR 62014, Nov. 25, 2009] § 415.180 Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic tests. (a) General rule. (1) In residency training sites that are located outside of a metropolitan statistical area only, physician fee schedule payment may also be made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a resident when the teaching physician is present through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the interpretation of review of the diagnostic radiology test. (2) For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, physician fee schedule payment may also be made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a resident when the teaching physician is present through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the interpretation or review of the diagnostic radiology or diagnostic test. (b) [Reserved] [85 FR 85037, Dec. 28, 2020] § 415.184 Psychiatric services. (a) Physician fee schedule payment is made for psychiatric services furnished under an approved GME program if the requirements of §§ 415.170 and 415.172 are met, including documentation, except that the requirement for the presence of the teaching physician during the service in which a resident is involved may be met by observation of the service by use of a one-way mirror, video equipment, or similar device. (b) In residency training sites that are located outside of a metropolitan statistical area, the requirement for the presence of the teaching physician during the service in which a resident is involved may be met through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the service. (c) For all teaching settings during the Public Health Emergency, as defined in § 400.200 of this chapter, for the COVID-19 pandemic, the requirement for the presence of the teaching physician during the service in which a resident is involved may also be met through audio/video real-time communications technology. The medical records must document the extent of the teaching physician's participation in the service. [85 FR 85037, Dec. 28, 2020] § 415.190 Conditions of payment: Assistants at surgery in teaching hospitals. (a) Basis, purpose, and scope. (1) A training program relating to the medical specialty required for the surgical procedure; and (2) A resident in a training program relating to the specialty required for the surgery available to serve as an assistant at surgery. (b) Definition. Assistant at surgery (c) Conditions for payment for assistants at surgery. (1) Are required as a result of exceptional medical circumstances. (2) Are complex medical procedures performed by a team of physicians, each performing a discrete, unique function integral to the performance of a complex medical procedure that requires the special skills of more than one physician. (3) Constitute concurrent medical care relating to a medical condition that requires the presence of, and active care by, a physician of another specialty during surgery. (4) Are medically required and are furnished by a physician who is primarily engaged in the field of surgery, and the primary surgeon does not use interns and residents in the surgical procedures that the surgeon performs (including preoperative and postoperative care). (5) Are not related to a surgical procedure for which CMS determines that assistants are used less than 5 percent of the time. Subpart E—Services of Residents § 415.200 Services of residents in approved GME programs. (a) General rules. (b) Exception. (c) Definitions. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.202 Services of residents not in approved GME programs. (a) General rules. (b) Payment. § 415.204 Services of residents in skilled nursing facilities and home health agencies. (a) Medicare Part A payment. (1) Skilled nursing facility. (2) Home health agency. (b) Medicare Part B payment. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.206 Services of residents in nonprovider settings. Patient care activities of residents in approved GME programs that are furnished in nonprovider settings are payable in one of the following two ways: (a) Direct GME payments. (b) Physician fee schedule. (i) The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry in the State in which the service is performed. (ii) The time spent in patient care activities in the nonprovider setting is not included in a teaching hospital's full-time equivalency resident count for the purpose of direct GME payments. (2) Payment may be made regardless of whether a resident is functioning within the scope of his or her GME program in the nonprovider setting. (3) If fee schedule payment is made for the resident's services in a nonprovider setting, payment must not be made for the services of a teaching physician. (4) The carrier must apply the physician fee schedule payment rules set forth in subpart A of part 414 of this chapter to payments for services furnished by a resident in a nonprovider setting. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005] § 415.208 Services of moonlighting residents. (a) Definition. services of moonlighting residents (b) Services in teaching hospitals. (2) Services of residents that are not related to their approved GME programs and are performed in an outpatient department or emergency department of a hospital in which they have their training program are covered as physician services and payable under the physician fee schedule if criteria in paragraphs (b)(2)(i) through (iii) of this section are met. The services of residents that are not related to their approved GME programs and are furnished to inpatients of a hospital in which they have their training program are covered as physician services and payable under the physician fee schedule if criteria in paragraphs (b)(2)(i) through (iii) of this section are met. The medical record must include documentation to demonstrate in each case that these criteria are satisfied. (i) The services are identifiable physician services and meet the conditions for payment of physician services to beneficiaries in providers in § 415.102(a). (ii) The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed. (iii) The services performed can be separately identified from those services that are required as part of the approved GME program. (3) If the criteria specified in paragraph (b)(2) of this section are met, the services of the moonlighting resident are considered to have been furnished by the individual in his or her capacity as a physician, rather than in the capacity of a resident. The carrier must review the contracts and agreements for these services to ensure compliance with the criteria specified in paragraph (b)(2) of this section. (4) No payment is made for services of a “teaching physician” associated with moonlighting services, and the time spent furnishing these services is not included in the teaching hospital's full-time equivalency count for the indirect GME payment (§ 412.105 of this chapter) and for the direct GME payment (§§ 413.75 through 413.83 of this chapter). (c) Other settings. [60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005; 85 FR 19289, Apr. 6, 2020; 85 FR 85037, Dec. 28, 2020]