Role of the Faculty, Levels of Supervision, and Billing Requirements

---

Faculty and Appropriate Resident Supervision

An appropriate level of supervision is also needed to ensure an optimal learning environment for trainees.  Residents who are asked to perform tasks they do not feel capable of performing without supervision may experience a significant level of stress that is not conducive to learning.  A key concept in autonomy and graduated independence is scaffolding, or provision of support to learners (such as helpful hints or a structure for organizing a differential diagnosis).  The concept of scaffolding suggests that as resident learners progress in their knowledge and clinical competency, the level of support (and by extension supervision) provided should decrease.  This allows for the progressive autonomy required for residents to gain the skills needed to become confident and independent practitioners after graduation.

Below are relevant excerpts from the ACGME Core Program Requirements that address supervision of residents as well as definitions of the various levels of supervision.

---

Excerpts from Common Program Requirements from ACGME

VI.D. Supervision of Residents 

VI.D.1. In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care. 

VI.D.1.a) This information should be available to residents, faculty members, and patients. 

VI.D.1.b) Residents and faculty members should inform patients of their respective roles in each patient’s care. 

VI.D.2. The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients

VI.D.5.a).(1) In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.] 

---

ACGME Clinical Learning Environment Review (CLER) Brief on Resident Supervision

https://www.acgme.org/Portals/0/PDFs/CLER/9704%20ACGME%20CLER%20Supervision_Digital_FINAL.pdf

---

General Surgery Program Requirements from ACGME and the Surgery RRC

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/440_GeneralSurgery_2019.pdf?ver=2019-06-19-092818-273

Graduate medical education has as a core tenet the graded authority and responsibility for patient care. The care of patients is undertaken with appropriate faculty supervision and conditional independence, allowing residents to attain the knowledge, skills, attitudes, and empathy required for autonomous practice. Graduate medical education develops physicians who focus on excellence in delivery of safe, equitable, affordable, quality care; and the health of the populations they serve. Graduate medical education values the strength that a diverse group of physicians brings to medical care. 

I.B. Participating Sites

I.B.6.d) The program director should designate other well-qualified surgeons to assist in the supervision and education of the residents.

IV.A.3. delineation of resident responsibilities for patient care, progressive responsibility for patient management, and graded supervision; (Core) 

Background and Intent: These responsibilities may generally be described by PGY level and specifically by Milestones progress as determined by the Clinical Competency Committee. This approach encourages the transition to competency-based education. An advanced learner may be granted more responsibility independent of PGY level and a learner needing more time to accomplish a certain task may do so in a focused rather than global manner.

IV.C. Curriculum Organization and Resident Experiences 

IV.C.1. The curriculum must be structured to optimize resident educational experiences, the length of these experiences, and supervisory continuity. (Core)

IV.C.5.a) The clinical assignments should be carefully structured to ensure that graded levels of responsibility, continuity in patient care, a balance between education and service, and progressive clinical experiences are achieved for each resident. (Core)

VI.A.2.a).(1) Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient’s care. (Core)

VI.A.2.b) Supervision may be exercised through a variety of methods. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member, fellow, or senior resident physician, either on site or by means of telephonic and/or electronic modalities. Some activities require the physical presence of the supervising faculty member. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback. 

VI.A.2.b).(1) The program must demonstrate that the appropriate level of supervision in place for all residents is based on each resident’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation. (Core)

VI.A.2.c) Levels of Supervision: To promote oversight of resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: (Core) 

VI.A.2.c).(1) Direct Supervision – the supervising physician is physically present with the resident and patient. (Core) 

VI.A.2.c).(2) Indirect Supervision: 

VI.A.2.c).(2).(a) with Direct Supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision. (Core) VI.A.2.c).

(2).(b) with Direct Supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision. (Core) 

VI.A.2.c).(3) Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. (Core) 

VI.A.2.d).(2) Faculty members functioning as supervising physicians must delegate portions of care to residents based on the needs of the patient and the skills of each resident. (Core)

VI.A.2.d).(3) Senior residents or fellows should serve in a supervisory role to junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow. (Detail) 

VI.A.2.e) Programs must set guidelines for circumstances and events in which residents must communicate with the supervising faculty member(s). (Core) 

VI.A.2.e).(1) Each resident must know the limits of their scope of authority, and the circumstances under which the resident is permitted to act with conditional independence. (Outcome) 

Background and Intent: The ACGME Glossary of Terms defines conditional independence as: Graded, progressive responsibility for patient care with defined oversight.

VI.A.2.e).(1).(a) Initially, PGY-1 residents must be supervised either directly, or indirectly with direct supervision immediately available. (Core) 

VI.A.2.e).(1).(a).(i) The program must define those physician tasks for which PGY-1 residents may be supervised indirectly, with direct supervision available, and must define “direct supervision” in the context of the program. (Detail)

VI.A.2.e).(1).(a).(ii) The program must define those physician tasks for which PGY-1 residents must be supervised directly until they have demonstrated competence as defined by the program director, and must maintain records of such demonstrations of competence. (Detail) (see below for an example)

VI.A.2.e).(1).(a).(iii) The program should use the template of definitions provided in the FAQ or a variation of the template to develop these definitions. (Detail) 

VI.A.2.f) Faculty supervision assignments must be of sufficient duration to assess the knowledge and skills of each resident and to delegate to the resident the appropriate level of patient care authority and responsibility. (Core)

An Example of a Housestaff Supervision Policy (Note that VI.A.2.e states that individual programs must specify which patient management activities and procedures require the specified (direct, indirect with direct supervision immediately available, indirect with direct supervision availability) level of supervision)

---

Definitions

Resident: 

A physician who is engaged in a graduate training program in surgery, and who participates in patient care under the direction of attending physicians (or licensed independent practitioners) as approved by each review committee. 

As part of their training program, residents are given graded and progressive responsibility according to the individual resident’s clinical experience, judgment, knowledge, and technical skill. Each resident must know the limits of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence. Residents are responsible for asking for help from the supervising physician (or other appropriate licensed practitioner) for the service they are rotating on when they are uncertain of diagnosis, how to perform a diagnostic or therapeutic procedure, or how to implement an appropriate plan of care. 

Supervising Physician (Attending of Record): 

An identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner) who is ultimately responsible for the management of the individual patient and for the supervision of residents involved in the care of the patient. The attending delegates portions of care to residents based on the needs of the patient and the skills of the residents. 

Supervision 

To ensure oversight of resident supervision and graded authority and responsibility, the following levels of supervision are recognized: 

1. Direct Supervision – the supervising physician is physically present with the resident and patient. 

2. Indirect Supervision: 

a) with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision. 

b) with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities and is available to come to the site of care in order to provide Direct Supervision. 

3. Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. 

Clinical Responsibilities 

The clinical responsibilities for each resident are based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. The specific role of each resident varies with their clinical rotation, experience, duration of clinical training, the patient’s illness and the clinical demands placed on the team. The following is a guide to the specific patient care responsibilities by year of clinical training. Residents must comply with the supervision standards of the service on which they are rotating unless otherwise specified by their program director. 

PGY-1 (Junior Residents) 

PGY-1 residents are primarily responsible for the care of patients under the guidance and supervision of the supervising physician and senior residents. They should generally be the point of first contact when questions or concerns arise about the care of their patients. However, when questions or concerns persist, supervising residents and/or the attending physician should be contacted in a timely fashion. PGY-1 residents are initially directly supervised and when merited will progress to being indirectly supervised with direct supervision immediately available by an attending or senior resident when appropriate. 

For PGY-1 residents, indirect supervision is allowed for the following: 

1. Patient Management Competencies 

a) evaluation and management of a patient admitted to hospital, including taking an initial history and conducting a physical examination, formulation of a plan of therapy, and determining necessary orders for therapy and tests 

b) pre-operative evaluation and management, including taking a history and conducting a physical examination, formulation of a plan of therapy, and specification of necessary tests 

c) evaluation and management of post-operative patients, including the conduct of monitoring and ordering medications, testing, and other treatments 

d) transfer of patients between hospital units or hospitals 

e) discharge of patients from the hospital 

f) interpretation of laboratory results 

2. Procedural Competencies 

a) performance of basic venous access procedures, including establishing intravenous access 

b) placement and removal of nasogastric tubes and Foley catheters 

c) arterial puncture for blood gases 

For PGY-1 residents, direct supervision (by either an attending physician, a licensed independent practitioner, or more senior resident) is required until competency is demonstrated for: 

1. Patient Management Competencies 

a) initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (Advanced Trauma Life Support (ATLS) required) 

b) evaluation and management of postoperative complications, including anuria, cardiac arrhythmias, change in neurologic status, change in respiratory rate, compartment syndromes, hypertension, hypotension, hypoxemia, oliguria 

c) evaluation and management of critically-ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments 

d) management of patients in cardiac or respiratory arrest (Advanced Cardiac Life Support (ACLS) required) 

 

e) evaluation patients with wounds and generation of proper wound care recommendations 

2. Procedural Competencies (the number of procedures required with direct supervision prior to being about to perform the procedures with indirect supervision is indicated in parenthesis after each procedure)

a) repair of surgical incisions of the skin and soft tissues (5)

b) repair of lacerations of the skin and soft tissues (5)

c) excision of lesions of the skin and subcutaneous tissues (5)

d) wound VAC placement (5)

e) bedside wound debridement (5)

f) bedside drainage of abscesses (5)

g) repair of vascular access devices (5)

h) performance of advanced vascular access procedures, including central venous catheterization, temporary dialysis access, and arterial cannulation (5)

i)tube thoracostomy (5)

j) paracentesis (5)

k) endotracheal intubation (10)

PGY- 2 to 3 (Intermediate Residents)

Intermediate residents may be directly or indirectly supervised by an attending physician or senior resident but will provide all services under supervision. They may supervise PGY-1 residents and/or medical students; however, the attending physician is ultimately responsible for the care of the patient. 

PGY- 4-6 (Senior Residents)

Senior residents may be directly or indirectly supervised. They may provide direct patient care, supervisory care or consultative services, with progressive graded responsibilities as merited. They must provide all services ultimately under the supervision of an attending physician. Senior residents should serve in a supervisory role of medical students, junior and intermediate residents in recognition of their progress towards independence, as appropriate to the needs of each patient and the skills of the senior resident; however, the attending physician is ultimately responsible for the care of the patient. 

Supervising Physician (Attending of Record) 

In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged primary attending physician (or licensed independent practitioner) who is ultimately responsible for that patient’s care. The attending physician is responsible for assuring the quality of care provided and for addressing any problems that occur in the care of patients and thus must be available to provide direct supervision when appropriate for optimal care of the patient and/or as indicated by individual program policy. The availability of the attending to the resident is expected to be greater with less experienced residents and with increased acuity of the patient’s illness. The attending must notify all residents on his or her team of when he or she should be called regarding a patient’s status. In addition to situations the individual attending would like to be notified of, the attending should include in his or her notification to residents all situations that require attending notification per program or hospital policy.  The primary attending physician may at times delegate supervisory responsibility to a consulting attending physician if a procedure is recommended by that consultant or to the emergency department attending physician if the patient is in the emergency department. The attending may specifically delegate portions of care to residents based on the needs of the patient and the skills of the residents and in accordance with hospital and/or departmental policies.

Supervision of Consults 

Residents may provide consultation services under the direction of supervisory residents including fellows. The attending of record is ultimately responsible for the care of the patient and thus must be available to provide direct supervision when appropriate for optimal care and/or as indicated by individual program policy. The availability of the attending and supervisory residents or fellows should be appropriate to the level of training, experience and competence of the consult resident and is expected to be greater with increasing acuity of the patient’s illness. Information regarding the availability of attendings and supervisory residents or fellows should be available to residents, faculty members, and patients. Residents performing consultations on patients are expected to communicate verbally with their supervising attending at regular time intervals (generally once every 24 hours, or more often if patient acuity necessitates more frequent communication). Any resident performing a consultation where there is credible concern for patient’s life or limb requiring the need for immediate invasive intervention MUST communicate directly with the supervising attending as soon as possible prior to intervention or discharge from the hospital, clinic or emergency department so long as this does not place the patient at risk. If the communication with the supervising attending is delayed due to ensuring patient safety, the resident will communicate with the supervising attending as soon as possible. Residents performing consultations will communicate the name of their supervising attending to the services requesting consultation.

Additional specific circumstances and events in which residents performing consultations must communicate with appropriate supervising faculty members include: 

• Any consultation in which it is anticipated that operative intervention will be required emergently or urgently 

• Any consultation in which procedures will be performed on the patient in the Emergency Department setting 

Resident Competence & Delegated Authority 

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members. The program director must evaluate each resident’s abilities based on specific criteria, guided by the Milestones. 

Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility. The attending and supervisory resident are expected to monitor competence of more junior residents through direct observation, formal ward rounds and review of the medical records of patients under their care. 

The attending may also delegate partial responsibility for supervision of junior residents to senior residents assigned to the service, but the attending must assure the competence of the senior resident before supervisory responsibility is delegated. Over time, the senior resident is expected to assume an increasingly larger role in patient care decision making. The attending remains responsible for assuring that appropriate supervision is occurring and is ultimately responsible for the patient’s care. Residents and attendings should inform patients of their respective roles in each patient’s care. 

Supervision of invasive procedures 

In a training program, as in any clinical practice, it is incumbent upon the physician to be aware of his/her own limitations in managing a given patient and to consult a physician with more expertise when necessary. When a resident requires supervision, this may be provided by a qualified member of the medical staff or by a resident who is authorized to perform the procedure independently. In all cases, the attending physician is ultimately responsible for the provision of care by residents. When there is any doubt about the need for supervision, the attending should be contacted. 

The following procedures may be performed with the indicated level of supervision: 

Direct supervision required by a qualified member of the medical staff 

• Any and all surgical procedures scheduled by an attending physician. Furthermore, all critical portions of these procedures will be directly supervised by the attending physician, regardless of PGY level 

• All clinic procedures performed by PGY4 and below residents 

• All on call and after hours surgical procedures not covered by below section on indirect supervision 

Indirect supervision required with direct supervision immediately available by a qualified member of the medical staff: 

• The following after-hours and on call procedures performed in the operating room: 

o Laceration repair 

o Abscess drainage 

o Minor debridement 

• Dressing change under anesthesia 

• Suture removal under anesthesia 

• Chest tube placement under anesthesia

• Clinic procedures performed by PGY5 and above residents: 

o Placement of seroma catheters

o Wound debridement and/or wound VAC placement

Oversight required by a qualified member of the medical staff 

• Emergency department procedures as follows: 

o Fracture reduction and splinting 

o Laceration repair 

o Bedside drainage of abscesses

• Inpatient ward procedures as follows: 

o Dressing removal or change 

Emergency Procedures 

It is recognized that in the provision of medical care, unanticipated and life-threatening events may occur. The resident may attempt any of the procedures normally requiring supervision in a case where death or irreversible loss of function in a patient is imminent, and an appropriate supervisory physician is not immediately available, and to wait for the availability of an appropriate supervisory physician would likely result in death or significant harm. The assistance of more qualified individuals should be requested as soon as practically possible. The appropriate supervising practitioner must be contacted and apprised of the situation as soon as possible. 

Circumstances in which Supervising Practitioner MUST be contacted 

There are specific circumstances and events in which residents must communicate with appropriate supervising faculty members. 

• Any time a patient has an acute change in medical status 

• Any transfers to a more acute setting (i.e. ICU) 

• Any change in code status to DNR, DNI, or comfort care

• For unexpected patient discharges (i.e. patient leaves facility against medical advice) 

If the supervising practitioner does not respond in a timely manner, the resident is to attempt to contact the supervising practitioner by cell or home phone via paging operator. If the supervising physician still does not respond, the resident is to contact the on-call attending physician for that date. 

---

Requirements for Timely and Accurate Clinical Documentation

Clinical documentation must be accurate and completed in a timely manner. Appropriate clinical documentation is critical for many reasons:  to justify a level of billing that is commensurate to the medical care provided, to convey the extent of co-morbidities and degree of illness that allows for appropriate risk assessment, and most importantly to allow accurate communication of the patient’s active medical issues, clinical course, and the thought processes of the treating physicians regarding the appropriate ongoing work up and treatment of the patient.  Documentation is paramount for optimal clinical care as it is a significant means of communication between care teams. Clinical documentation is also used by insurance companies to determine the level of reimbursement to be provided to a medical facility or provider, as well as to determine whether or not additional diagnostic imaging and testing will be covered.  

Supervising physicians have a responsibility to ensure that all documentation by a resident is timely and accurate. There are specific documentation requirements as set forth by the Centers for Medicare and Medicaid Services (CMS) that must be followed to be compliant. It is important that an appropriate level of documentation is provided in either the resident’s note and/or the addendum from the supervising physician. Additionally, the level of oversight provided by the supervising physician must also be accurately documented. 

---

CMS (Centers for Medicare and Medicaid Services) Requirements for Resident Supervision

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf

Medicare pays for services furnished in teaching settings through the Medicare Physician Fee Schedule (PFS) if the services meet one of these criteria: 

● They are personally furnished by a physician who is not a resident 

● They are furnished by a resident when a teaching physician is physically present during the critical or key portions of the service 

Billing Requirements for Teaching Physicians You must be identified as the teaching physician who involves residents in the care of your patients on claims. Claims must comply with requirements in the General Documentation Guidelines and E/M Documentation Guidelines sections. Claims must include the GC modifier, “This service has been performed in part by a resident under the direction of a teaching physician,” for each service, unless the service is furnished under the primary care exception. When the GC modifier is included on a claim, you or another appropriate billing provider are certifying that you complied with these requirements.

EVALUATION AND MANAGEMENT (E/M) DOCUMENTATION GUIDELINES For a given encounter, select the appropriate level of E/M service code according to the definitions of the code in CPT® books and any applicable documentation guidelines. When you bill E/M services, you must personally document at least all of the following: 

● That you performed the service or were physically present during the critical or key portions of the service furnished by the resident and 

● Your participation in the management of the patient On medical review, the combined entries in the medical record by you and the resident constitute the documentation for the service and together must support the medical necessity of the service. Documentation by the resident of your presence and participation is not sufficient to establish such presence and participation.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf

Minor Procedures: For procedures that take only a few minutes (five minutes or less) to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure.

---

Additional Resources

Kantor O¹, Schneider AB¹, Rojnica M¹, Benjamin AJ¹, Schindler N², Posner MC¹, Matthews JB¹, Roggin KK³.  Implementing a resident acute care surgery service: Improving resident education and patient care.  Surgery. 2017 Mar;161(3):876-883. doi: 10.1016/j.surg.2016.09.033. Epub 2016 Dec 5.

Allen M¹, Gawad N², Park L³, Raîche I².  J Surg Res.  The Educational Role of Autonomy in Medical Training: A Scoping Review.  2019 Aug;240:1-16. doi: 10.1016/j.jss.2019.02.034. Epub 2019 Mar 22.

Sandhu G¹, Thompson-Burdine J², Matusko N³, Sutzko DC⁴, Nikolian VC⁵, Boniakowski A⁶, Georgoff PE⁷, Prabhu KA⁸, Minter RM⁹.  Am J Surg.  Bridging the gap: The intersection of entrustability and perceived autonomy for surgical residents in the OR.  2019 Feb;217(2):276-280. doi: 10.1016/j.amjsurg.2018.07.057. Epub 2018 Aug 27.

Williams RG¹, George BC², Bohnen JD³, Meyerson SL⁴, Schuller MC⁴, Meier AH⁵, Torbeck L⁶, Mandell SP⁷, Mullen JT³, Smink DS⁸, Chipman JG⁹, Auyang ED¹⁰, Terhune KP¹¹, Wise PE¹², Choi J⁶, Foley EF¹³, Choti MA¹⁴, Are C¹⁵, Soper N⁴, Zwischenberger JB¹⁶, Dunnington GL⁶, Lillemoe KD³, Fryer JP⁴; Procedural Learning and Safety Collaborative.  Is the operative autonomy granted to a resident consistent with operative performance quality.  Surgery. 2018 Sep;164(3):566-570. doi: 10.1016/j.surg.2018.04.034. Epub 2018 Jun 19.

Lindeman B¹, Sarosi GA².  Competency-based resident education: The United States perspective.  Surgery. 2019 Aug 2. pii: S0039-6060(19)30364-2. doi: 10.1016/j.surg.2019.05.059. [Epub ahead of print