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ITINERANT SURGERY

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OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS 
APRIL 1989  - ",
OFFICE OF INSPECTOR GENERAL 
The mission of the Offce of Inspector General (OIG) is to promote the efficiency, effective
ness and integrty of program in the United States Deparent of Health and Human Services 
(HS). It does ths by developing methods to detect and prevent frud, waste, and abuse. 
Create by statute in 1976, the Inspector Genera keeps both the Secretar and the Congrss 
fuly and curntly inormed about program or management problems and recommends cor
rective action. The OIG performs its mision by conductig audits, investigations, and inspec
sta 
tions with approximately 1,200  strategically located around the countr. 
OFFICE OF ANALYSIS AND INSPECTIONS 
Ths report is produced by the Office of Analysis and Inspections (0Al, one of the thee 
major offces within the OIG. The other two ar the Offce of Audit and the Office of Inves
tigations. Inspections ar conducted in accordance with professional standar developed 
OAl These inspections ar tyicaly short-term studies designed to determe program effec
tiveness, effciency, and vuerabilty to fraud or abuse. 
Th study was conducted to determe quality of car issues related to itierat surgery and 
Medicare made overpayments to itinerat surgeons for servces not provided. 
The report was prepard under the diction of Don McLaughli, the Regional Inspector 
General of Region VI, Office of Analysis and Inspections. Parcipating in this project were 
the followig people: 
Headquarters 
Kansas 
Bar 
(Project Leader)  Steeley 
Tun Dold 

Har 
Phil 0 ' Kitty Ahern 
Deborah Walden  Mar Hogan 
James Wolf 
Alicia Smith  ITINERANT SURGERY

Richard P. Kusserow 
INSPECTOR GENERAL 
OAI-07 -88-00850  APRIL 1989  EXECUTIVE SUMMARY 
OBJECTIVES 
This inspection report focuses on issues involving itie ant surgery. The overall objective of 
the inspection was to determne: 
the extent of itinerant surgery in 
rual hospitals; 
the extent to which qualty  itinerant surgery; and 
of car is affected by 
the extent to which itierant surgeons bil global fees that include postoperative care 
they did not provide. 
BACKGROUND 
Itinerant surgery is defmed in this inspection as the practice by a physician (normally residing 
ru 
in another city) of traveling to smal  hospitals to perform surgery. The surgeon typically 
is not available for follow-up care, havig trveled to another rural hospita or returned to his 
or her home base all in the same day. The American College of Surgeons 
wil and have ex
cluded physicians from fellowship for performng itinerat surgery. However, medical 
var 
opinions  greatly regardig the necessity and ethics of itinerat surgery and its effect on 
the quality of patient car. 
METHODOLOGY 
A random sample of 72 hospitals was selected from the universe of 1,328 rura hospitals with 
50 beds or fewer. We then determned which of the sample hospitals used the services of 
itierant surgeons. Medicare beneficiares' admssion records in the 20 hospitals which util
ized itierat surgeons, durng October 1, 1985 though September 30, 1986, were screened 
for the 12 most frequently reported surgical diagnosis related groups (DRGs) in rural hospi
DRGs at the sample hospitas were selected for review. Contact 
tals. All surgeries in those 
with the hospitas determed if local or itinerat surgeons had performed the surgeries in 
question. 
Reimbursement was analyzed by comparng documentation in the medical records to the bil
ing and payment informtion frm Medicar payment histories. The medical records were 
then reviewed by a medical review contractor to assess quality of care. Contacts were made 
with severa organizations, including the American College of Surgeons, the American Medi
cal Association, the American Academy of Family Physicians, peer review organizations 
(PROs), and State medical licensure boards, to obtain their views on itinerant surgery.  FINDINGS 
Some Rural Hospitals Make Extensive Use Of Itinerant Surgery 
Twenty-eight percent (20 of 72) of the sampled rual hospitals utilized itinerant 
surgeons. Itinerat surgeons performed 73 percent (177 of 242) of the sample cases 
which were selected from the 12 most common surgeries in the sampled rural facilities. 
Many Rural Hospitals See Itinerant Surgery As A Cost-effective Means Of Providing 
Needed Surgery Which Might Not Otherwise Be Available In Some Rural Areas 
Nevertheless, There Is A Higher-than-average Risk Of Poor Quality Care In Itinerant 
Surgery 
Physicians under contract to the Offce of Inspector General (OIG) identified 29 cases 
(16.3 percent) with adverse outcomes. In 10 of these cases, the adverse outcome was 
aggravated by itierant surgery.

Contract physicians found that 123 (70 percent) of the cases reviewed were elective 
surgeries. Furer, 8 percent of those elective surgeries were found to be 
. contraidicated. 
Contract physicians identified 41 cases in which a surgical note was not present before 
where notes were present, the notes were not adequate. The 
anesthesia. In 10 cases 
review also identied 29 cases where the preoperative workup was not adequate. 
The overall rate of poor quality care in this study was determned to be 26.6 percent. In 
comparson, the National DRG Validation Study completed by the OIG found a 3.3 
percent rate of poor quality care in surgical cases in smal rural hospitals. 
Medicare Pays Many Itinerant Surgeons For Postoperative Care Which Is Not Performed 
Review of medical records and payment histories found that, in 113 of 177 (63. 
percent) of the records reviewed, the itinerant surgeons did not provide postoperative 
care. However, they biled the Medicare program. a global fee which included this care.  RECOMMENDATIONS 
To Improve The Quality Of Care In Itinerant Surgery Cases 
Rural physicians and hospital admnistrators should develop and monitor 
implementation of procedures to ensure adequacy of: 
preoperative workups; 
the patient s opportnity to seek a second opinion; 
postoperative plans of care; and 
postoperative communication between the attending physician and the itinerant 
surgeon. 
The Health Care Financing Admistrtion (HCF A) should require that PROs review 
procedures performed by itinerant surgeons to determne if the qualty of patient care is 
afected when preoperative or postoperative car is not provided by the itinerant 
surgeon. Parcular attention should be paid to adverse outcomes related to itinerant 
surgery . 
To Recover And Reduce Overpayments For Postoperative Care Billed, But Not Performed 
By, Itinerant Surgeons 
The HCF A should instrct Medicare carers to recover overpayments from itinerant 
surgeons identied in this study who  not provide 
biled a global fee but did 
postoperative car.

The HCFA should instrct all carers to use proedur code modifier "54" to eliminate 
Medicare overpayments in cases where itinerant surgeons provided surgery only. The 
HCFA should instrct all carers to educate surgeons regarding the use of the "54" 
modier. 
The HCF A should develop guidelines regarding the percentage allocation of global fees 
for surgery and postoperative care. These guidelines would provide criteria for 
consistent claims adjudication, and should be dissemiated nationwide. 
AGENCY COMMENTS 
The HCFA comments reflect general agreement with the findings and recommendations in 
this report. The OIG is pleased that HCFA is takng action to implement the maj"rity of these 
recommendations. However, HCFA did not agre with the recommendation that PROs should 
review itinerant surgery procedures because such a review would require a new review proce
dure, and itinerant surgeons cannot be identied from non-itinerant surgeons. Although we  recognize the efforts expended by PROs, we believe that a review of itinerant surgeries should 
not requir an extensive revision of procedures since the scope of work currently includes 
rual hospitals, and local PROs should be aware of itinerat surgeons in their service area. 
HEALTH ORGANIZATION COMMENTS 
The OIG issued the draft report to six health organzations for comments, of which two (the 
American Hospita Association and the American Academy of Famy Physicians) responded. 
In general, both organzations were in agreement with the majority of the report recommenda
tions. However, these organizations also shard a concern that the conclusions in the report 
were reached from a small sample of surgical cases. The sampling process, as in all inspec
tions, is approved by GIG statistical sta to ensur accuracy and consistency of the inspection 
process. The fidings from this study were based on the analysis of data drawn from valid ran
dom samples.  ............................. ....... .................... .... ........  ........................ ............................ .... ........ ................................... .... ..................................... ...... ............  
.......................... ................................ .... .......... ........ . ......... ......... ................ ......... ........... ....................  .... .. .. .... ... 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION .. ............ .................. ........... 
II.... 1 
o BJ ECTIVES ............. .... ............ .....  .....811 1 
BAcKG ROU N D . 
ETHODOLOG Y ............. ............... ...... ... 
FINDI NGS .......... ......  a.. 6

......... ....... ... .......11
RECOMMENDATIONS AND AGENCY cOMMENTS.........................................

APPENDICES .... ........  .......................... It...... .
 INTRODUCTION

OBJECTIVES 
Ths national inspection focuses on issues involving the quality of care related to inpatient 
progr 
itierant surgery, and on Medicare  overpayments to itinerat surgeons for postopera
ervices not provided. The overal objective of the inspection was to determne: 
tive s
itierat 
the frequency of  surgery; 
the extent to which a physician other than the itierant surgeon provides preoperative 
and/or postoperative care; 
the extent to which the qualty of car is affected by the surgeon s absence; 
if itierant surgeons ar biling global fees which include postoperative car they did not 
provide; 
Medicare carer procedures and policies regarding global fees; and 
the amount of Medicare program overpayments resulting from payments of global fees 
biled by itinerat surgeons for services not provided. 
BACKGROUND 
Itinerant surgery is defined in this inspection as the practice by a physician (normally residing 
in another city) of travellig to small rual hospitals to performr suur gery. The surgeon typically 
is not available for follow-up care, havig trveled to another  hospita or retured to his 
or her home base all in the same day. In most of these cases, preoperative and postoperative 
care is performed by the patient s local attndig physician rather than the itinerant surgeon. 
ru 
Itierant surgery occur in smal  hospitals for severa reasons. A hospital may not have 
local surgeon, yet surgical patients prefer to be hospitaized in their local hospital. Where 
ocal surgeon, he or she is usually a general surgeon. A surgical specialist (e. 
there is a 

urologist or'orthopedist) may be required for other than general surgery. This specialist would 
tyicaly be an itinerat surgeon, even if resident in a rura area, since small hospitals cannot 
support a specialst on a full-time basis. 
Usually, an attendig physician admts a patient and is responsible for the care the patient 
receives. When surgery is required, a surgeon consults with the attendig physician, examines 
the patient, performs the surgery, and provides surgical aftercare, such as ordering antibiotics, 
fluid replacement, and the type and frequency of dressing changes.  As mentioned above, some small rual hospitals do not have a patient population large enough 
to support general and/or specialized surgeons, so surgery is often performed by an itinerant 
surgeon. Whether an itinerat surgeon performs all or pan of the preoperative or postopera
tive care, or shares that care with the attendig physician, depends on the surgeon and can 
var from case to case. This practice raises concerns regarding the quality of care rural 
Medicare patients receive and whether Medicare payments to itinerant surgeons cover services 
not provided. 
var 
Medical opinions  greatly regarding the necessity and ethics of itinerant surgery and its ef
fect on the qualty of patient care. Medical jourals have included arcles about itinerant 
surgery which question whether surgery should be performed by an itierant surgeon if the 
operation cares with it a signcant risk; or whether itinerat surgery is ethical because a sur
tus it 
geon abandons the patient s postoperative car and  over to another physician. 
durg 
Severa organizations contacted  the coure of this inspection, including the American 
College of Surgeons (ACS), have wrtten guidelies and/or set a policy regarding itinerant 
surgery. The ACS prohibits its members from performng itinerant surgery. Their bylaws 
tu 
state that it is unethical to  over the postoperative care of a patient to another physician 
who is not as well qualified to undertake it. A fiding that itinerat surgery was performed 
may lead to a member s expulsion by the ACS Board of Regents. In one specifc case, the 
ACS excluded a physician from fellowship because he performed itinerant surgery. 
On the other hand, a representative of the American Medical Association stated that itinerant 
surgery is an "accepted and necessar" practice. A representative of the American Academy of 
Famy Physicians stated that itierant surgery can represent quality medical care if the follow
ing crteria are met:

The surgeon is competent to provide surgery; 
the surgeon and the attending physician enter into a defied agreement regarding the 
provision of aftercar;

services are provided in a competent hospital; and 
there is adequate postoperative communication between the surgeon and the attending 
physician. 
Surgical procedure codes used by physicians in billng for medical/surgical procedures are 
ar 
Physicians (CPT) Manual and 
listed in the  ' Current Procedural Terminology  similar to the 
Health Care Financing Admnistrtion (HCFA) Common Procedure Coding System (HCPCS). 
The HCPCS codes for surgery provide a "global allowance" for surgical procedures and un
complicated postoperative care. In instances when only a portion of the global service is per
formed (i.e., surgery only), a procedure code with a two-digit modifer provides the means 
which the physician can indicate when the scope of a surgical procedure has been altered. The  CPT modier "  " used with the procedure code, indicates that the surgeon performed only 
the surgery and did not provide postoperative car. The HCFA guidelines require that al car
riers be able to accept clais biled with a five-digit HCPCS code and up to two modifiers. 
However, carers may elect not to use the modiers for pricing or profiing puroses. 
progr 
Medicare  overpayments may result when surgeons do not provide postoperative care 
and submit bils using a procedure code without a modier. Overpayments may also result 
bilgs 
with proper  using modiers for surgery only if the carer payment system does not 
recognize the modier and pays for a global servce. 
METHODOLOGY 
The inspection methodology was completed in the following steps. (See appendi I for out
line.) First, a random sample of72 hospitas was selected from the universe of 1 328 rural 
hospitals of 50 beds or fewer which were located in aras outside Metropolitan Statistical 
Areas as defmed by the Census Bureau. Second, the hospitals in the sample were contacted to 
determe if itierant  In 11 of the 72 hospitals 
surgeries were performed in those facilties. 
(15 percent), no surgery was performed. Forty-one hospitals (57 percent) used only local staff 
were performed in the remaining 20 hospitals (28 percent) lo
surgeons. Itinerat surgeries 
cated in 14 States.

Figure 1

72 SAMPLED RURAL HOSPITALS 
SURGEONS BY LOCAL 
SURGEONS (41 Hospitals) 
NO SURGERY 
PERFORMED (11 Hospitals) 
ITINERANT SURGERY 
PERFORMED (20 Hospitals) 
15.
 Third, Medicar beneficiares ' admssion records in the 20 hospitals, durng the period 
October 1, 1985 though September 30, 1986, were screened for the following 12 most fre
quently reported surgical diagnosis related groups (DRGs) in rual hospitals: 
DRG  Description 
Extr Craal Vascular Procedures 
Lens Procedurs 
148  Major Smal and Large Bowel Procedures 
154  Stomach, Esophageal, Duodenal Procedures 
157  Anal Procedurs 
Repai 
161  Ingunal and Femoral Hernia 
197  Total Cholecystectomy 
209  Major Joint Procedurs 
210  Hip and Femur (Except Major Joint) Procedures 
257  Total Mastectomy, Malignancy 
310  Transurthal Procedures 
336  Transurthal Prostatectomy 
A tota of 243 surgical admssions of Medicare beneficiares in the 20 hospitals was selected 
initially as the sample for this inspection. One hospita was dropped from the inspection be
cause it had only one identied admssion in that hospita and in that parcular Medicare 
carer s ara. 
Four, the review team identied, though discussions with hospital sta and review of medi
cal records, that 177 of the remaing 242 surgeries were performed by itinerat surgeons. 
found that over hal of these surgeries were performed by itinerat surgeons in the surgical 
specialties of ophthalology, urology, and ortopedics. The remaining 65 surgeries were per
formed by local attendig physicians (30 cases) or by local surgeons (35 cases). 
The Office of Inspector General (GIG) contracted with the Forensic Medical Advisory Service 
of Rockvlle, Marland, to perfonn a qualty of care review of the 177 sampled itierant 
surgery records. The OIG specifed that the contrctor provide medical review and wrtten as
sessment of the quality of car of servces provided to patients trated by itierant surgeons 
identied in the sample. 
The 177 medical records were examned to determne if they reflected problems related to an 
acceptable quality of care, and the extent of preoperative and postoperative sel"vices provided 
by the itierant surgeon. The scope of review did not include a review of patient visits, if any, 
to the surgeon s office after the hospital discharge.  involve varous 
Qualty of car could 
aspects of surgery and include quality of the surgery, complications following surgery, and the 
provision of preoperative and/or postoperative care by the surgeon, as documented in the 
medical record. 
Since the 177 medical records included severa types of surgery, the contrctor used board
certfied physician reviewers who included general surgeons and also specialty surgeons who  reviewed cases in their respective specialties. The physician reviewers, using professional 
judgment, completed a narative summar and an abstraction of data elements on each of the 
177 cases. A list of the data elements is included as appendi II. 
Beneficiar payment histories for the 177 itinerant surgery admissions were obtained from 
Medicare carers. The HCFA guidelines provide for payment of a global fee to the surgeon 
for the surgical procedure and postoperative care unless postoperative care is not provided. 
progr 
Medicare  overpayments were calculated for cases in which it was determined that the 
the Medicare program a global fee. The 
surgeon provided no postoperative car, yet biled 
respective carer guidelies were used in calculatig Medicare program overpayments. The 
carers vared in the number of postoperative days included in the global fee; however, the 
days. See appendi III 
most frquent period was 14  for details. 
Discussions were held with itinerat surgeons, attending physicians, hospital administrators, 
billg 
surgeons  offices, State medical boards, and peer review organizations (PROs) in the 
States where on-site hospital visits were made. Several health organizations were contacted to 
obtain views regardig itinerant surgery as it relates to qualty of care.  FINDINGS 
Some Rural Hospitals Make Extensive Use Of Itinerant Surgery 
Twenty-eight percent (20 of 72) of the sampled rural hospitals utilized an itinerant surgeon. 
Itierant surgeons performed 73 percentr ouf t he sample cases (177 of 242) covering the 12 
most common surgeries in the sampled  facilities. The 177 surgeries were performed by 
43 itinerat surgeons.

ITINERANT SURGERY SAMPLE 
Total  Surgery Performed by  No. of Itinerant 
No. of 
Hospital  Beds  Cases  Local Surgeon  Itinerant Surgeon  Surgeons 
TOTALS  242  177 
Durg 
intervews with 11 of the 43 itinerant surgeons, we found that 5 of the 11 were from 
cities with a population greater than 50,000 and were specialists (such as orthopedic sur
geons). Six of the 11 itinerat surgeons were from small cities (less than 25,000 population) 
or towns similar in size to the towns where itinerant surgery occurred, and were usually 
general surgeons.

Many Rural Hospitals See Itinerant Surgery As A Cost-effective Means Of Providing 
Needed Surgery Which Might Not Otherwise Be Available In Some Rural Areas 
The practice of itinerant surgery in a rural hospita is perceived to have a beneficial impact on 
the hospital, the community, local physicians, and patients.  -- 
....---.....---- ._.. __._._ ----'---- - . -.  ----. .. ---- --.---  _.n 
Rural Medicare patients feel they can benefit from itinerat surgery. By having surgery at the 
local hospital, the patient is not subjected to the truma of going to an unfamiliar hospital and 
the associated problem of transportation to the hospita for the patient, his or her famly and 
frends. 
The local attendig physician also benefits from itinerant surgery. Because his or her patients 
are able to have surgery at the local hospita rather than transferrng to another hospital, the at
in many cases, could not be done if 
tendig physician can provide daiy medical care which, 
the patient had to be sent to another city for surgical care. 
From the rual hospital's point of view, itierant surgery enables the hospital to keep surgical 
patipentrs, ith ereby improving occupancy and hospita income. Since many rual hospitals are 
the  employer in the communty, itierant surgery can also indiectly effect the employ
ment of community residents. 
We intervewed itinerant surgeons, attending physicians, and hospital admnistrators from 
ru 
communities. Some of their opinons regardig itinerant surgery follow: 
is vital to the surval of rual hospitals and rural communities who 
Itierat surgery 
fear that referrg patients to larger hospitals means losing them forever; 
without itinerat surgery, the quality of rual medicine would suffer; 
itinerant surgery performed localy costs less, while maintaining the same quality as 
surgeries performed in larger hospitas; and 
surgery performed locally alows patients to remain close to their friends and family, 
elimnating the social and economic problems associated with transferrng to a hospital 
outside the community. 
In summar, itierant surgery provides a needed service to local physicians, the rural hospi
tals, patients, and residents of rual communities. 
Nevertheless, There Is A Higher-than-average Risk Of Poor "
Quality Care In Itinerant 
Surgery 
car 
Contract physicians identified problems related to the quality of  associated with itinerant

surgery. The following types of problems were identified within the sample of cases:

There were adverse outcomes related to a number of the surgeries, some of which were 
also aggrvated by itinerant surgery. 
Properative work-ups were inadequate.  Surgical follow-up was not performed. 
Discussion of the more signicant qualty of care issues follows. 
Adverse Outcomes Aggravated by Itinerant Surgery 
The review determed that 29 of the 177 cases (16.3 percent) had adverse outcomes that were 
related to surgery performed by itierant surgeons. In 10 of those cases, the physician 
reviewers determed that the adverse outcomes were not only related to the surgery, but were 
also aggravated by itinerant surgery. The contract physicians defined "aggravated by itinerant 
surgery" to mean that the adverse outcomes were made worse because the surgery was per
formed by an itierat surgeon who did not provide sufficient medical care before and/or after 
surgery. The following are examples of these cases, as described by the physician reviewers: 
An 84-year-old woman had a breast mass biopsied under general anesthesia despite 
multiple medical problems contrndicatig general anesthesia. The surgeon 
preoperative note for the biopsy did not mention her medical problems. She 
subsequently suffered severe postanesthetic complications. Despite these 
complications, and despite the fact that the biopsy was in essence a segmental 
mastectomy (paral breast removal), the surgeon elected to perform a second surgery--a 
modied radical mastectomy--again under general anesthesia. The patient developed 
respiratory distrss and ultiately cardiac arest from which she expired on the third 
postoperative day. The surgeon did not see the patient after either surgery, and, indeed, 
may not have been awar of her near-demise following the biopsy. Both the use of 
general anesthesia and radical surgery in this high-risk patient were contraindicated. 
At discharge 7 days after a cholecystectomy (galbladder removal), a 68-year-old man 
drage 
contiued to have bile  from a drai left in place. The surgeon did not see the 
patient postoperatively, despite the continuing bilous drainage, which could have 
represented injur to the liver bed, the common bile duct, or the cystic duct during 
surgery. The postoperative management was grossly unsatisfactory, since this 
complication required surgical rather than medical management. 
A 73-year-old man had a hernia repair under local anesthesia. There was no indication 
that he was seen postoperatively by the surgeon or the attending physician, and he was 
discharged with the wound stil bleeding. He was readmtted by a third physician 2 
days postoperatively with hemorrhage in the area of the hernia, cellulitis, and jaundice. 
Ths represents unacceptable postoperative care, with complications aggravated by the 
surgeon s inattendance. 
In 5 of these 10 cases, the itinerat surgeon did not provide postoperative care. In the 
remaining cases, only limited postoperative car was provided. In all 10 cases, postoperative 
care, when present, was provided by the patient s attending physician.  Other Adverse Outcomes Related to Surgery 
The review also found that the remaiing 19 cases with adverse outcomes were related to the 
surgery performed by the itierat surgeons. In 15 of these cases, the surgeon either did not 
provide postoperative care or provided only limited postoperative care. The physician 
reviewers cited examples of adverse outcomes related to surgery: 
In thee cases, patients had urnar incontinence following resections of the prostate. In 
none of these cases was the patient seen by the surgeon postoperatively, although the 
postoperative complication was related to the surgery. 
The preoperative workup on an 84-year-old woman admtted with abdominal pain was 
inadequate. As a result, the surgeon operated for suspected perforated divertculitis. 
When he did not fid it, he closed the incision, made another, and removed a 
noniamed galbladder. It was inappropriate to remove the gallbladder unnecessarly 
in a high-risk patient. The surgeon faied to either diagnose or treat the acute perforated 
ulcer that caused the admssion. 
Inadequate Surgical Notes Before Anesthesia 
In 41 cases, a surgical note was not present before anesthesia was admistered to the patient. 
The medical review contractor stated that the lack of a surgical note before anesthesia suggests 
that the patient had not been seen and evaluated by the itinerat surgeon prior to the ad
miistration of anesthesia. 
In the remaiing 136 cases, a surgical note before anesthesia was documented in the medical 
records. However, in 10 of the 136 cases, the surgical notes before anesthesia were not ade
quate. In these cases, the surgical notes did not adequately describe an evaluation of the 
patient prior to surgery or explain the indications for surgery. 
Figure 2

SURGICAL NOTES BEFORE ANESTHESIA 
UNIVERSE OF 177 ITINERANT SURGERY CASES 
1m 
PRESENT & ADEQUATE 
NOT PRESENT 
tZ 
PRESENT BUT 
NOT ADEQUATE  Inadequate Preoperative Workups 
The preoperative workup prior to surgery, as reflected in the medical records, was not ade
quate in 29 cases. In these cases, the evaluations of the patient by the attending physician and 
the itinerat surgeon were both considered. Some of the most common deficiencies reported 
were a lack of documentation that certai exams and certain laboratory and radiological tests 
were performed. Also, there was insufficient evaluation of a patient s prior medical history to 
make a diagnosis. 
Contraindicated Surgery 
Analysis of data from the physician reviewers found that 123 of the 177 itinerant surgeries (70 
percent) were elective surgeres. The reviewers also found that in 10 of those 123 surgical 
cases (8 percent), the elective surgery was contraidicated. These 10 surgeries were per
formed by itierant surgeons in the surgical specialties of urology, ophthalmology, and general 
surgery. Thee of these surgical cases were among those with adverse outcomes described 
above. 
Overall Quality Of Care Was Significantly Worse In These Cases Than In A Random 
Sample Of Surgical Cases In Small Rural Hospitals 
As discussed above, this study identified a 16) percent rate of adverse outcomes directly re
itierat 
lated to  surgery. These outcomes were not necessarly indicative of the overall 
durg 
quality of car rendered  the hospital stay. In some instanc;es, the adverse outcome 
could have been that the patient was known to be a very poor surgical risk who wanted to un
dergo surgery in any case. On the other hand, cases with poor quality of care overall did not 
necessary result in an adverse outcome. No comparable data exists for a related population 
(Le., surgical cases in  hospitas, performed by local surgeons) to determine if 
smal 
the adverse outcomes. 
itierant surgery alone accounts for 
However, the OIG has conducted a major analysis of qualty of care, in a random sample of 
050 records from 239 hospitas under the prospective payment system. Furter analysis of 
data from ths study, caled the National DRG Validation Study, revealed that 30 surgical cases 
had been reviewed which met the  itinerant surgery study: 
crteria established for the 
the cases occurd in rural hospitals with 50 or fewer beds; and 
the surgical procedures involved the 12 DRGs most commonly performed in rural 
hospitals. 
The rate of poor quality car in this national validation subsample was 3.3 percent (1 case' out 
, however, is not fully comparble to  3 percent rate of adverse 
of 30). This 3.3 percent the 16.
outcomes in this itinerant surgery study, as the national validation study measured the overall 
quality of car, rather than the outcome alone. In order to compar quality, the OIG medical  officer who examned the qualty summares from the National DRG Validation Study (to en 
sure consistency of the reviewers ' judgments) also reviewed the summares wrtten by Foren
sic Medical Advisory Servce. He applied the same crteria to the itinerant surgery cases that 
had been applied in the earlier study. The medical offcer determned that the comparable rate 
of poor qualty car in the itierat surgery sample was 26.6 percent (47 out of 177 cases). 
This dierence in rates of poor qualty car (3.3 percent vs. 26.6 percent) is statistically sig
nifcant (Chi-squar = 6.5, p = 0.0107; Fisher s exact test, p = 0.00216). Thus the observed 
dierences are highly unlely to be due to chance alone. 
Figure 3

RELATIVE RATES OF POOR QUALITY CARE  II 
NATIONAL DRG VALIDATION STUDY  POOR CARE
VS.  ITINERANT STUDY  I2 
GOOD CARE 
96.  73.4% 
National DRG Validation Study  Itinerant Surgery Study 
Sample size 30  Sample size 177 
Analysis of information obtained in this review of a sample of records indicates an association 
between poor quality of car and itinerant surgery. Although not diectly attbuted to itinerant 
surgery, poor quality of care occurd usually with the findings of no preoperative care, no 
outcome with the itinerant surgery cases in this inspec
postoperative car, and/or an adverse 
inadequate preoperative workups, and/or no postoperative 
tion. Insufficient patient histories, 
care existed in cases aggrvated by itinerant surgery. Itinerant surgeons, in many cases, do not 
see their patients prior to the day of surgery and, for this reason, may not receive a complete 
picture of the patient s medical history or problems. In addition, preoperative workups may 
be inadequate. The fact that many itinerat surgeons provide no postoperative or limited pos
toperative care may contrbute to postsurgical complications aggravating an adverse outcome. 
(See appendix III. 
In summar, this comparson indicates that itierant surgery may result in poor quality of care 
delivered in hospitals that use itinerant surgeons.  Medicare Pays Many Itinerant Surgeons For Postoperative Care Which Is Not Performed 
No Postoperative Care by the Surgeon 
The review of individual medical records for aftercare by the surgeon focused on written 
entres in the record signed by or on behal of the itinerant surgeon. Among the areas 
reviewed in each record was the postoperative period, which was defined as beginning the day 
after surgery and including al subsequent days unti the day of discharge. Of the 177 medical 
records reviewed, 116 contaied no documented entres of postoperative care by the itinerant 
surgeons who performed the surgeries. In these cases, the postoperative care, when present 
was provided by the attendig physicians. A breakout of the 116 cases and the number of 
days in the postoperative period is shown below. 
Number of  Number of 
Cases  Postoperative Days 
1 to 4 
5 t07 
8 to 10 
11 to 14 
15 or more 
Since global fees are intended to cover postoperative care, an analysis was conducted of the 
Medicar carer payment histories for those 116 admssions to determne if the itinerant sur
geons biled for global fees when, in fact, they had performed surgery only. The carers ' pay
ment histories reflect that the itierant surgeons were paid a global fee by the Medicare 
progr 
without a surgery-only modier in 113 cases. In the remaining three cases, the 
itierant surgeons biled with a surgery-only modifier.

Based on our analysis, 28 of 43 itierat surgeons (65 percent) were overpaid a total of 
$15,387 by Medicar for postoperative car that was biled using a global fee code, but was 
not provided. If the Medicar program paid itierat surgeons only for surgery, it could have 
saved $289,927 nationaly. The methodology that was used to calculate the program overpay
ments and savings is outled in appendix IV. 
Limited Postoperative Care By the Surgeon 
In 45 cases, itierant surgeons provided limited postoperative care of at least one day or more 
beginning the day after surgery. In 39 cases, the itierant surgeons were paid a global fee. In 
the remaiing six cases, the itinerant surgeons biled with a modifier. 
The 45 medical records and payment histories were reviewed in the same manner as described 
in the previous finding. The number of cases and the identified number of limited postopera
tive hospital visits are shown below.  Number of  Postoperative

Cases  Visits

3 or more 
Overpayments were not calculated on the 39 cases where limited postoperative visits were 
made because specifc  which would identiy the number of postoperative 
crteria do not exist 
visits requird in order to qualy for payment for surgical aftercare. 
Use of the Modifier " 54" 
Of the 12 carers contacted in this inspection, 10 adjust global fees based on the physician 
use of the procedur code moder "  " which indicates the surgeon performed only surgery 
and did not provide postoperative care. The other two carers do not recognize the modifier 
" and routinely pay global fees (appendix V, column A). Thus, the two carers ' proce
dures do not alow for adjustments to the global fees. 
Variance in Global Fees 
There ar no HCFA guidelines regarding: 
the number of postoperative days covered by a global fee; and 
the percentage of the global fee alocated for the surgery and for postoperative care. 
We contacted the Medicar carers servicing the clais in this inspection regarding global 
fees. Of the 12 carers, 4 base the number of postoperative days included in the global fee on 
the procedur or tye of surgery performed. The postoperative period covered by the global 
fee for the other eight carers vared by tye of surgery and ranged from 10 to 45 days (appen
di V, column B). The carers also reponed the percentage of the global fee allocated for sur
gical car and for postoperative car. The alocations ranged from 80/20 to 70/30. The 
varance in global fee allocations is shown in appendix V, column C. 
Because of the laGk of a common policy covering the number of postoperative days covered 
by the global fee and the alocated amounts for a global fee, nationwide varances exist in 
program adjustments and/or payments, unrlated to surgical procedurs or practices.  RECOMMENDATIONS AND AGENCY COMMENTS 
Improve The Quality Of Care In Itinerant Surgery Cases 
RECOMMNDA nON - Rural physicians and hospita admnistrtors should develop and 
monitor implementation of procedurs to ensure adequacy of: 
preoperative work:ps 
the patient s opportity to seek a second opinion; 
postoperative plans of care; and 
postoperative communcation between the attending physician and the itinerant surgeon. 
AGENCY COlVNTS - The HCFA stated that although this recommendation is not directed 
to the PROs, it should be noted that the PROs currently review records to ascertain that care 
delivered to Medicar beneficiares in both urban and rual ural settings meets acceptable 
standards. This review includes preadmssion/admssion workups and discharge planning. 
The HCFA also stated that the patient, 'lie al Medicare beneficiares, can seek a second 
opinion under Medicare s voluntar second opinion progrm. 
OIGRESPONSE - The OIG supports the PRO' s review of quality of car in rural as well as 
urban settgs. However, the ultiatre ure sponsibilty for care in hospitals rests on hospital ad
ministrators and physicians. In the  settng, the Medicare patient s abilty to seek a 
second opinion must be faciltated. 
RECOMMA nON - The HCFA should requir that PROs review procedures performed 
by itinerat surgeons to determne if the qualty of patient care is afected because preopera
tive or postoperative car is not provided by the surgeon. Parcular attention should be paid 
to adverse outcomes related to itinerat surgery. 
AGENCY COlVNTS - The HCFA does not agre with ths recommendation for the follow
ing reasons: (1) Sufcient data does not exist to perform the analysis necessar to justify 
revising the PRO scope of work and implementing a new review procedure. In addition 
under the curnt review process, PROs review a significant percentage of hospital admissions 
and intensify review where quality problems are identified. Therefore, any patterns of quality 
problems with a physician wil be identified and resolved, and (2) "Itinerant" surgeons are not 
identied separately from "non-itinerant" surgeons. PROs would not have the means to iden
tify and focus on these surgeons. Therefore, it would riot be feasible to implement this type of 
reVIew. 
OIG RESPONSE - We recognize the efforts now expended by PRO' s in their review of rural 
as well as urban hospitas. However, because of the joint car being provided by itinerant 
surgery, we contiue to believe that a review of all surgeries is waranted. In small hospitals,  ''_.-  --""' ' ..,..-. .- --- .. -.' .":::.... -i-....  -f- ...':a.  ':....;.--",,  ' -'" ...--...  :. '''''''' o.. -". ':v.,"_ '''..:.. :-.,,".. ......-.:...... ,_......._:" '-. _" ":--',;--",--" ,-",,, --'
it would not be dicult to identiy though hospital admstration those surgeons who prac
tice itierant surgery. Also, miimal new review procedure should be required, and local 
PROs should be awar of itierant surgeons in their service area. 
Recover And Reduce Medicare Overpayments For Postoperative Care Biled But Not Per
formed By Itinerant Surgeons 
RECOIvNDA TION - The HCFA should instrct Medicar carers to recover overpay
ments from itierat surgeons identied in this study who biled a global fee but did not 
provide postoperative care. 
AGENCY COMrNTS - The HCFA agred that overpayments should be recovered where 
payment was made for servces that were not performed. HCFA stated that each afected car
rier wi be 
so instrcted. 
tive care. 
OIG RESPONSE - The OIG wil proVide a list to HCFA of each affected carer and the 
itierat 
respective names of  surgeons who  not provide postopera
biled a global fee but did 
RECOIvNDATION - The HCFA should instrct all carers to require the use of proce
dure code modier "54" to elimiate Medicar overpayments in cases where itinerant sur
geons provided surgery only. The HCFA should also instrct carers to: 
educate surgeons regardig the use of modifiers for itierant surgery cases; and 
identiy rual hospitals that allow itierant surgery. All claims for surgery performed in 
these rual hospitals by itinerant surgeons should be reviewed to determne the extent 
itierat surgery and the bilng of global fees including the use of the modifier "54. 
Action should be taken to recover any incorrct payments identied. 
AGENCY COIvNTS - The HCFA agred that the use of modier "54" is importt in 
cases where itierant surgeons provide surgery only and they are remiding al carers of the 
use of all CPT-4 modiers as pan of the 1989 HCFA Common Procedure Coding System up
date. 
OIG RESPONSE - We ar pleased that HCFA concurs with the importance of modifiers when 
only a porton of services represented by a global fee are performed, and that HCFA is remind
ing carers of the use of modifiers. However, in their comments, HCFA failed to address the 
remaining pans of the recommendation. The OIG continues to recommend that HCFA in
strct carf'rs to educate surgeons regarding the:use of modifiers. In addition, claims for 
itinerant surgery should be reviewed to detect global fee problems and recover any incorrct 
payments.  "'-. ._-,- "",",. " '.. -..-..-. ":.._ :.--...; .--. - ... .g_.. -  ". _....; .-.' -.--:._-"".. --..... .-... - -.- .:_--..';---- -..-..-,...  ...-:.-- .... ...:..-. -"--''__..__ ':'- ....
"'.-. "0_ 
RECOMMNDATION - The HCFA should develop guidelines regardig the percentage al
location of global fees for surgery and postoperative care. These guidelines would provide 
criteria for consistent claims adjudication, and should be disseminated nationwide. 
AGENCY COMMNTS - The HCFA stated "As pan of our effort to develop a uniform defini
tion of servces, as required by section 4055(a)(2) of the Omnibus Budget Reconcilation Act 
of 1987, we ar considerig establishig a uniorm reduction in the global charge where the 
surgeon does not perform the postoperative car. 
OIG RESPONSE - We ar pleased that the HCFA is takng action to identiy mechanisms per
tinent to implementig this recommendation. 
RECOMMENDATION - The HCFA should review the issue of limited postoperative care and 
consider whether policy should be established to determne a minimal level of postoperative 
care which would justiy payment of a global fee. 
AGENCY COMMNTS - The HCFA stated that they will consider the need for a minimum 
standard for postoperative care before a global charge is recognized. 
OIG RESPONSE - We ar pleased that HCFA's comments reflect a positive response. We 
believe a national defIntion of the car which must be rendered to justify postoperative pay
ments is clearly needed. 
AGEN. COMMENTS 
GENERAL  cY 
The HCFA stated that although the OIG provided percentages and several examples to 
demonstrte poor qualty of care, it did not present the rep  rt in a manner which would permit 
them to fully analyze its results. The HCFA also stated that the meang of the statement "the 
adverse outcome was aggravated by the itierat surgery" was not explaied. In addition, 
HCFA suggested that it would be very useful to have the qualty of car problems further 
defmed by the actual  severity. A copy of HCFA's comments is included 
tye of problems and 
in appendi VI. 
OIG RESPONSE - We appreciate HCFA's comments regarding the content and presentation 
of this report. The qualty of care findigs in this report ar based on the results of analysis of 
itierant surgery cases by the medical review contractor. Their analysis included the use of 
some descrptive terms, e.  cases had adverse outcomes" and "aggravated by itinerat 
surgery" that descrbed the severity of poor quality of care. The medical contractor was not 
asked to describe each identified finding by the specific tye of problem. We believe this 
report includes suffcient descrptions and case examples of poor quality car to support our 
conclusions.  Health Organization Comments 
The OIG issued the draf inspection report on "Itierant Surgery" to six health organizations 
for comments, with responses received frm the American Hospita Association and the 
American Academy of Famly Physicians. Copies of the comments are included in appendix 
VI. The remaing four organizations did not respond. The following is a sumnar of the 
commehts received from the American Hospital Association and the American Academy of 
Famy Physicians. 
The American Hospita Association commented, regardig our sampling methodology, that 
broad conclusions were inappropriately drawn frm a small sample and that data from this 
study was inappropriately compard to data from an earlier unrlated study. The American 
Hospita Association did not agree with the recommendation regarding the PROs review of 
itinerant surgery procedures and the recommendation on second opinions for itinerant surgery. 
However, the American Hospital Association said on the whole the recommendations in the 
report seem quite sensible. Specifcaly, the American Hospita Association agred with the 
ru 
recommendation that  physicians and hospita admnistrtors develop procedurs to en
sue pre- and postoperative car and to improve communication between the attending 
physician and the itierant surgeon. Ths recommendation agrees with a document prepard 
by the American Hospita Association called "Guidelines-Creentialing of Outreach Sur
durg 
geons," which was sent to al Association members  1988 and was included as attach
ment A with the Association comments (see-appendi VI). In addition, the American Hospital 
Association is in agreement with the report recommendations dealng with the recovery of 
regarg 
overpayments and instrctions to Medicare carers and physicians  the use of 
moders for 
improved billng procedurs. 
The American Academy of Famy Physicians questioned the extent of the quality problems re
lated to itierat surgery because of the smal number of cases reviewed, the absence of a con
trol grup and medical criteria to suppon judgements, and whether the medcal reviewers 
were, in fact, tre peers of the physicians being reviewed. . 
In genera however, the American Academy of Famy Physicians indicated agrement with 
the report recommendations. Their comments, in pan, states that "protocols to assur quality 
care and optimal outcomes when outrach surgery is performed should be instituted in 
hospitals where these services are performed." The Academy also worked closely with the 
American Hospital Association to develop the guidelines contaed in appendi VI of this 
report. 
In other areas, the American Academy of Famy Physicians supports the education of all the 
physicians involved in itinerat surgery in regard to the use of modfiers. The Academy also 
indicated that HCFA should oversee the uniform application of modfier "54" by all carers in-
eludig the education of physicians regarding the proper use of pertnent moders. 
progr 
OIG RESPONSE - We appreciate receiving comments to the  inspection report from 
organizations that are so important to medical care tody such as the American Hospital As
sociation and the American Academy of Famy Physicians.  ----'
" " .." .-.......-_.....,,- ........ .. " --.. . ":'';- .._ -- -_.._ .. -, ...._,--- . :-'... ""._..-._-",...._ "-,,,-,,-,,--, ;;" .. ""-'  '''--''--'
_a - -Oon... --- _..  O",_. -."".O
In their comments both organzations shard a concern that conclusions were reached from a 
smal sample of surgical cases. The design and methodology for this inspection, as for all 
program inspections, are approved by OIG statistical staff to ensure accuracy and consistency 
of the inspection process. The conclusions or findings in this parcular study are based on the 
analysis of facts and data drawn from vald radom samples.  APPENDIX I 
Sampling Methodology 
Universe of Hospitals 
ru 
1328 - hospitas identied nationwide, 50 beds or fewer, and not located in 
metropolitan statistical areas 
Sample of Hospitals 
hospitals selected at random and contacted to determe if itinerant surgery was 
performed in the facilty 
hospitals dropped from sample of 72 
no surgery was performed in the hospital 
no itinerant surgeon(s) used or no major surgery was 
performed in the hospital 
identied with at least 1 itinerant surgeon 
hospitals located in 14 States 
Admissions 
243  adssions identified at the 20 hospitals using the 12 most common surgical 
diagnosis-related groups (DRGs) in rual hospitals 
admssion dropped from the sample (only case at that hospital and carer) 
242	 total number of hospital admission records reviewed to determine frequency of 
itinerant surgery 
records dropped (surgery performed by local surgeon or attending physician) 
Itinerant Surgery Cases 
177  records of itinerant surgery 
records excluded from furer review (itinerant surgeon provided complete 
postoperative care)  Payment Histories 
161	 beneficiar payment histories reviewed (from 12 carers) for global fee billngs 
and use of modifier "54" 
records excluded from furer review (itinerant surgeon biled using a modifier 
54" 
Medicare Overpayment 
152  global fee paid for no or limted postoperative care 
113	 no postoperative care 
lited 
postoperative car (not included in overpayment calculation)  '-_--"
..., _.__...__.._..-,. -- -o---.__. ..-: -., .. ,_.; _:,.. ,-. _.. ""--,, -:._...."....,.. :. '.._._..- __ r__..... ",,,""-";..-..-...--" " "'''''_.J_...._  '.._'''. ---'-
APPENDIX II 
Data Elements 
IDENTIFICATION/DEMOGRAPHIC ELEMENTS 
A. Unique Number:

B. HIC Number:

c. Date of Surgery:

D. Age:

E. Race:

F. Sex:

G. Lengt of Stay: 
1. Prop length of stay: 
H. 
Preoperative Physician: 
1. Surgeon: 
J. Postoperative Physician 1: 
K. 
Postoperative Physician 2: 
L. Postoperative Physician 3:

M. Discharge Status: 
(fiN) 
1. Alive at discharge? 

Transferred to other hospital? (fiN) 
a. 
Transferred to swing bed? (fiN)
b. 
c.  Transferred to skiled care facilty? (fiN) 
Transferred to nursing home? (fiN)
d. 
Transferred to other facility? (fiN) 
e. 
Transferred home? (fiN) 
(fiN) 
2. Expired? 
 .. 
. ,--,,  '--' ""''- -. --'-'---""-;. . " ..- - .__. .,- :.- .__....g..,  "' ''- -_.. ..-. -,- ......"'"'-....- ':- ,.. :. :...... .... ... '-.. ... ----';"".._ . .....
II.  QUALITY OF CARE ELEMENTS 
A. Preoperative:

1. Indication for surgery:

Documented? (Y/N)
a. 
Valid indication? (Y/N)
b. 
Elective? (Y/N)
c. 
Contraindication? (Y/N) 
d. 
Statement of contraidication:

By attending? (Y/N)
i. 
By surgeon? (Y/N) 
n. 
By other? (Y/N) 
ii. 
2. Surgical note before anesthesia:

Present? (Y/N) 
a. 
Adequate? (Y/N)
b. 
clearce: 
3. Surgical 
Present? (Y/N) 
a. 
Adequate? (Y/N) .
b. 
By attending? (Y/N) 
c. 
By surgeon? (Y/N)
d. 
By other? (Y/N)
e. 
4. Properative workup:

Adequate? (Y/N)
a. 
By attending? (Y/N)
b. 
By surgeon? (Y/N)
c. 
By other? (Y/N)
d. 
5.  (Y/N) 
Was surgery appropriate to settng? 
B. Postoperative:

1. Frequency of surgical follow-up: 
Day of surgery only? (Y/N)
a. 
Day after surgery only? (Y/N)
b. 
Approximately once per week? (Y/N) 
c. 
Approximately twice per week? (Y/N)
d. 
Daily? (Y/N) 
e. 
None? (Y/N) 
f. 
Other? (Y/N)  g. 
2. Frequency of attendig follow-up: 
Day of surgery only? (YIN) 
a. 
Day after surgery only? (YIN) 
b. 
Approximately once per week? (YIN) 
c. 
Approximately twice per week? (YIN)
d. 
Daily? (YIN) 
e. 
None? (YIN) 
f. 
Other? (YIN) 
3. Adverse outcome? (Y  IN) 
Related to surgery? (YIN)
a. 
Aggravated by itinerant surgery? (YIN)
b. 
Who responded:
c. 
Attending? (YIN) 
i. 
Surgeon? (YIN) 
ii. 
No one? (YIN) 
iii. 
Other? (YIN) 
iv. 
IlL  Reviewer 
Date Reviewed  APPENDIX II 
Provider Itinerant Surgery Cases with Findings 
Number of 
Surgeries by 
an Itinerant  No Preoperative  No Postoperative  Adverse  Poor 
Provider  Surgeon  Evaluation  Examination  Outcome  Quality 
Totals  177  116  :. -" '
APPENDIX IV 
Methodology to Calculate Overpayments 
A program overpayment of $15,387 exists for the 113 cases reviewed for the period of the 
study where the surgeon biled a global fee and provided no postoperative care. Program 
savings of $289,927 were projected for the nation. These calculations were made as follows: 
Program Overpayments

The global-fee allowable charge on each case was adjusted based on the global-fee split 
used by the applicable carer. The global-fee split is a percentage reduction of the 
alowable charge. For example, a global fee of $100 for only the surgery using a 80/20 
global-fee split would result in an allowable charge of $80, which would be subject to 
the 20 percent coinsurance amount due from the Medicare beneficiar. 
Four carers stated they used an 80/20 global-fee split, and two carers stated they used 
a 70/30 split. The remaining carers stated they either did not recognize the use of 
modifiers or did not have a global-fee split. For these carers, a split of 80/20 was used 
for calculations. 
Once the allowable charge was adjusted for each case, a new payment amount was 
determned. The overpayment is the difference between the original payment and the 
revised payment amount. 
Program Savings 
The national projection of savings is based on a radom sample of 1,328 rural hospitals. 
The inspection found that itierat surgery is performed in 28 percent of the sample 
hospitals. The projection is computed only on those cases where the itinerant surgegn 
did not provide postoperative care,. but biled a global fee. The projected savings would 
be larger if the cases involving limited postoperative care were included.  APPENDIX V

And Global Fee Data
Carrier Use Of Modifier 	 54" 
Use of  Postoperative  Global Fee 
Days Included  urgery/P ostoperative 
Modifer 
Carrier  (Surgery Only)  (1)  Percentage Allocation 
in the Global Fee 
N/ A (2) 
Yes  80/20 
Yes  N/A 
Yes  Varable  Varable 
Yes  Varable  70/30 
Yes  80/20 
Yes  Varable  75/25 
Yes  80/20 
N/A 
Yes  Varable  70/30 
N/A. 
Yes 
Yes  80/20 
(1)	 With some carers, the alowance for postoperative days may depend on the surgical 
progr. 
procedur code biled to the Medicare  With those carers, the postoperative 
days var from one procedure to another. 
(2)	 N/A" (not applicable) applies to those carers which either do not use a modifier (car
riers A and I) or make an adjustment after reviewing charges instead of using a percent
age alocation of the global fee (carers C and K).  APPENDIX VI

The Draft Report 
Text Of Comments  On  .. ... _... ._.._.1"'_- ,,  .:' - .;:... .- _.._.: .: .. - -  .-.-'-.. -- -.. "  - ..h... -_ :"u-.  ----_.. .--..- _. . .___
14'\dllh '. J'V 
J)EPART,\EXT Uf IU..  lTH 6; Hl' \\A!' SEU\ ICES  r: .1I:,n\:"'\1 A,I"''''''  11 iI ioU' \ 
3 92 
p1ora
""r ' - T'  :":O'  (N:f
u r r...  L; . '. . '
C.t& 
William 1.. Roper, MI. D.  1989 JAN  9: S I 
Adinistrator 
Frorn 
Itinerat 
OIa Draft Report: - Surgery - OAI-07-88-00850 
Subject 
"'e Inspetor General 
Office of the Secretary 
drft 
inspetion  examned the 
We have revierwuedl  the OIa  report which 
extent to which  hospitals utilize itinerat surgeons, the potential
pratices 
impat of i  urgery on quali ty of cae, and the billini 
tinerat 
of itinerat surgeons. 
i ty, 
we are submit tine our comen ts to each
reomIn tehe nintdertesit oof
n in an attahment. 
drft 
i ving us the opprtun  to comnt on this 
repoThratn .y ou for 

Attachment 
RECEIVED

JAN 06 1988

OF.FICE OJ;

INSe.Ec:O.  J;N.ERAV

"I,_,.ft , . , = . -:- ';: .....- .
Health Care Financing Administration 
Comments on the 01 G Draft Report 
l t i nerant Surg 
88-00850 
Recommendat ion 

Rural physicians and hospital administrators should develop and monitor 
of: 
implementation of procedures to ensure adequacy 
preoperative workups;

the patients . opportunity to seek a second opinion;

postoperative plans of care; and

postoperative communication between the attending physician

and the itinerant surgeon.

HCFA Comments: 
While this recommendation is not directed at the Peer Review Organization 
(PRO) program, 'it should be noted that the PROs currently review-1o 
ascertain that care delivered to Medicare beneficiaries in both urban and 
rural settings meets acceptable standards. (This includes 
preadmission/admission workups and discharge planning.  In addition , the 
patient, like all Medicare beneficiaries, can seek a second opinion under 
Medicare  s voluntary second opinion program. 
Recommendation 2: 
The HCFA should require th.t PROs review procedures performed by itinerant 
surgeons to determine if the quality of patient care is affected because 
preoperative or postoperative care is not provided by the itinerant
surgeon. Particular attention 
should be paid to adverse outcomes related 
to itinerant surgery. 
HCF A Conments: 
We do not agree with the recommendation that HCFA require PROs to review

reasons.

procedures performed by itinerant surgeons for the following 
(1) We do not. have sufficient data to perform the ana lyses necessary 
RO scope of work and implementing a new
to justify revising the 

review procedure. While the OIG indicates that they identified a 
significant number of quality problems, we have no indication as 
problem. 
to the severity and type of quality  PROs already review 
a significant percentage of hospital ad issions and intensify 
review where quality problems "are identified. Therefore, under 
the current PRO review process, any patterns of quality problems 
resolved. 
with a physician will be identified and  . " 
:.. . . ' ,..  . ." ... - :
. . . .-._ .... . -- .'- . . .. - . ... --. ". - - . -..  ' ..h.. 
...". -. _... .- ;. . -. --.. ";. " " ... ...: ';;.- -.. '#.- - ....
Page 2

(2) " 
Itinerant" surgeons are not identified separ tely from 
itinerant" surgeons. 
non- PROs would not have the means to 
identify and focus on these surgeons. Therefore, ; t 
wou 1 d not be 
feasible to implement this type review. 
Recommendat ion 3:

The HCFA should instruct Medicare carriers to recover overpayments from

itinerant surgeons who billed a global fee but did not provide

pos toper at i ve care. 
HCFA Conuents:

We agree that overpayments shou 1 d be recovered where payment was made for
services that were not performed. Each affected carrier wi 11 be so 
instructed. 
Recommendation 4: 
The HCFA should instruct all carriers to require the use of procedure code 
modifier 54 to eliminate Medicare overpayments in cases where itinerant 
surgeons provi ded surgery on 1 y. 
HCFA Comments: 
We agree that the use of modifier 54 (Surgical Care Only) is i.mprtaftt in 
only. Additionally, t 
cases where itinerant surgeons provided surgery 
appropriate use of modifiers 52 (Reduced Services), 55 (Postoperative 
Management Only) and 56 (Preoperative Management Only) wi 11 alert carriers 
to situations requiring adjustments to a global allowance. We are 
reminding carriers of the use of all CPT-4 modifiers as part of the 1989 
HCFA Commn Procedure Coding System update. 
Recommendat ion 5:

The HCFA should develop guidelines regarding the percentage allocation of

global fees for surgery and postoperative care. These guidelines would

provide criteria for consistent claims adjudication, and should be

disseminated nationwide. 
Recommendation 6: 
The HCFA should review the issue of limited postoperative care and 
consider whether policy should be established to deter ine a minimal level 
of postoperative ' 
care which would justify payment of a global fee.  Page 3

HCFA Comments to Recommendations 5 and 

As part of our effort to develop a uniform definition of services, as

required by section 4055(a)(2) of the Omnibus Budget Reconciliation Act of

1987, we are considering establishing a uniform reduction in the global
charge where the surgeon does not perform the postoperat i ve care. We wi 11 
consider the need for a minimum standard for postoperative care before a 
global charge is recognized. 
Genera 1 Comments: 
The DIG provi des general percentages of "cases wi th poor qual i ty care, 
" II 
cases with adverse outcomes,  cases where the adverse outcome was 
aggravated by the itinerant surgery," and "cases of elective surgeries 
1I While they provide several examples to

found to be contraindicated.
demons trate poor qual i ty care, they do not present the report in a manner 
results. 
which would permit us to fully analyze their  For example, a case 
care, so the point that 
can have an aqyerse outcome without poor quality 
16. 3 percent of the cases had adverse outcomes is not meaningful. 
The DIG also states that in 10 cases, the adverse outcome was lI aggravated 
by the itinerant surgery.  However, the meaning of this statement is not
explained. It 
would be very useful to have the quality problems further
defi ned by the actual 
type of prob 1 em and severi ty, i. e., how many were 
documentati on problems; how many were unnecessary surgery; how many were

poor surgi ca 1 techn i ques; and what was the' sever; ty 1 eve 1 of the qua 1; ty 
prob 1 em.
 . . -- -------..--...  --; 
- .  . --.. . " ,  .- - --- . . --,.. - -..-... .". .:."...._--\- --- '--.'....-. h.__..  . -.... , . -.. ....- .-...-..
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Hospital Alloclatlon.
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C, Sunh uk,' Shll'" i)riw  1;, .;;aU""nll.r. IC'h:rhll'h  vuo.r ,- I. .. .  I.:. IU. 
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"II. AJJr u A.\lJi( )!I'  1999 J!lN -3  M 11: S3 
RECEIVED; 
Dece  ber 16, 1988 
JAN 061981

Richard P. Xusserow

Inspector Ceneral OFFCE OF

Office of Inspector Ceneral  INSPECTOR GENERAL

BaS North Building, Room 5250

330 Independence Avenue, S.
Washington, DC .20201 
re:  Draft report on Itinerant Surgery lOAI-07-88-00850 
Dear Mr. !tusserow 
On behalf of its nearly 6, bers, the A erican Hospital

000 institutional

Association appreciates this opportunity to comment on the draft report,

Itinerant Surgery  "Which was prepared by the Inspector General's Office of

Analysis and Inspections. 
Ye bave reviewed the report carefully, and agree with the report
recommendation c  lling for hospital internal procedures to ensure adequacy of
pre and post operative care and improved patient/ physician and
pbysiciau/ suraeon commnication. 
This recommendation is in concert wi th the 
attached guidelines for the credentialing of outreach surgeons which were

AB to all 
recently developed and sent by the  ber hospitals. We also

port recommendations which would corr ct apparent disparities in the

intermediaries.

billins rules established by fiscal 
hover, 
. Ve do DOt,  support the recommndation whch calls for a separate or 
procedures. Itinerant 
distinct review of itinerant surgical  surgery should be 
procedure 
subject to review within tbe sa e parameters 8S any surgical 
performed within the local hospital. 
Nor do we agree with the reco mendation calling for mandated second opinions

on itinerate surgery. The methodology used in cond  tins the survey, which is 
tde basis of the findings and these patticular recommendations, is seriously
flawed. 
Broad conclusions are inappropriately drawn from an extremely small 
survey sa  ple, and data from this study are inappropriately co pared to data 
from an e&rlier unrelated study. Moreover, the study only focused on 
pot.ntial adverse outcomes; there was no attempt to identify and report on 
o.it1ve results which would have provided a balanced perspective.

Setting aside the .ethodplogical problems, the report generally presents a 
balanced discussion of differing opinions of itinerant sursery by various
professional groups. Even here, however, the report lacks  ajor contextual 
elements. It does not address the frequency of this practice by rural 
hospitals on either a nationwide or regional basis, which was one of the 
stated objectives for the study. Nor does it address t e value of the 
eeting the psycho-social needs of an elderly,

practice in terms of cost or in 
 , '
less mobile rural population. Finally, it does not discuss the impact on 
rural populations, communities, and hospitals if the practice were not 
available. 
n alternative to

The decision on whether to offer itinerant surgery as 

out-of-area care is one that should be made by rural hospitals and their 
communities. If offered, it is important that hospitals ensure the quality of
this servce, as 
well as determine and apply appropriate criteria for 
servce. It is 
credentialing the physicians and surgeons who provide the 
important that hospitals and physicians receive clear instructions regarding 
physician billing modifications to reflect this practice. 
We hope these comments will provide a useful perspective. If you have any

questions, please address them to 5yl Boeder (312/280-6442) in our Chicago

office or to Milton Dezube (202/638-2318) in our Washington Office.

Snrcerely 
:e p. 

Carol M. McCarthy t Ph.D. t J.

cc:  J ames Wolf 
legional Inspector General
 , .
Commen t s 
Draft Report on

Itinerant Surgery

by the  Office of Inspector General

American Hospi tal Association

December 1988

000 hospital

The American Hospital Association, on behalf of its nearly 6,
members, welcomes this opportunity to submit comments on the HHS Office of

Inspector General' Itinerant Surgery  Comments are organized

s draft report on 

according to the subheadings that appear in the report.

OBJECTIVES 
Our primary concern is related to the degree to which the stated objectives 
are actually addressed in the final report. We find no evidence that anv 
.ubstant  iafer88tiDn in the report addresses tne frequency of itinerant 
ugnout the nation. Nor does the report

surgery in rural hospitals 

indicate any variation in frequency of the practice from region to region

which adght assist in identifying regional practice patterns and their impact

_challs... 
on billing or payment 
In assessing itinerant surgery, a more balanced perspective which also

presents positive aspects of this pr.c 1ce \particular y in areas of the

country where it is the only option because of distance or lack of local

physicians) would be helpful. The extreme limitations of the small study

sample also preclude .aking generalized statements of broad app!1Cabi!1

regarding quality, billing practices, and the relationship between itinerant

surgery and quality of care.

IAC  GROUN 
While the report presents - a balanced discussion of varying positions on 
appropriateness of itinerant 8urgery, it fails to address the impact on rural

In correctly

populations 8Dd hospitals if the practice vas not available. 
servce, no info  tion 
identifying sparse, rural populations as users of this 
ding alternatives to itinerant surgery tbat might be

waasv iancilu dead b
 le, at vhat d1stan e and cost. To many elde  ly rural residents, the 
hom 
psycho-social aspects of receiving care close to  and family weigh heavily 
in their choice to seek care locally.

The discussion regarding sur ical coding procedure requirements indicates

considerable variation in billing rreeqguiarremdeinntsu cby  fiscal intermediaries.

There is, however, no information  differences in codin 
requirements vhich would have affected tbe billing for the specific procedures

reviewed in this report.
 , '
METHODOLOGY 
h8n 50 beds, the size 
Given the universe of 1,328 rural hospitals with fewer 
small in 
of the random sample selected (72 hospitals) .seems unrealisticall3 
structuring a report which seeks to provide broad findings on the practice of
itinerant surgery throughout the .country. The further narrowing of the sample 
through removal of those hospitals in which no itinerant surgery was performed

percent, to a mere

has reduced an already small sample by over seventy-two 
nineteen hospitals. It is necessary, therefore, to question the generalizing

of findings Dased on such a narrow field of study.

In January, 1988, the American Hospital Association submitted a letter to the

Regional Office of the Inspector General requesting clarification of the

records,
qualifications of individuals who would conduct the review of medical 
as well as the criteria and methodology which would be used to conduct the 
review. We find no indication in the draft report that reviewers were 
. familiar with 
small rural hospital operational capabilities, practitioner 
hat the study 
arrangements or resource availability. Nor 40 we find evidence 
incorporates adequate consult'ation with physicians involved in the particular 
cases under consideration. This lack of evidence raises questions regarding
inadequate, rather
findings based solely on charting and coding which may be 

than on additional and substantive information as to the quality of care
provided. A statement on page 5, "The scope of review did not include a 
s office after the hospital 
review of patient visits, if any, to the surgeon 
discharge  " is indicative of the absence of additio al data which might affect 
erative 
the outcome of the survey For example, a lack of information on pre-o 
patient was
workup in the inpatient chart ..y be due to the fact that the 
8 office.
originally seen in an outpatient 8ettina, perhaps in the physicia

The same could be true of post operati  DOtea, particularly if the procedure

was done as same day or outpatient .urgery. In this instance, the physician

could have clarified a circumstance which would not have been apparent from a

Further8re, the 
review of written material.  lack of communication between 
. reviewing physicians and the physicians wh provided the care --a standard 
element of peer review protocols-- lea e8 open the question of the degree to 
quality proble. cited were a fUDtion of inadequate
which .any of the 

charting or of inadequate care.

The secondary methodology which involves tbe use of a separate study conducted 
Study) is a180 
for an entirely different purp08e (The ..tioaal DIG V.lidation 
a cause of concern. 
There 1s certainly question as to the comparability of
purpQse. ID
findings based on a sample preselected for an entirely different 

iverse of
itself, a  a u 
addition, the problem of small numbers again presents 
comparable t  those
050 records is narrowed to thirty surgical cases deemed 
used in the itinerant surgery study. To e8tablish a comparative percentage of 
poor quali ty care determined by one case in thirty also brings into question 
Sample. 
the validity of using the National DiG V.l1dation Study 
FINDINGS 
SOME RURAL HOSPITALS MA EXTENSIVE USE OF ITINERAN SURGERY 
6), is 
This statement, which opens the Findings section of the report (page  .., , '.,-_. .: ::. ; ..- _. " -, . ".: : -. ... . "-- - ,. , . ' . , p.
::"r_-:..w..  I .'0 '- J 
data. It 
inappr  t.1y  b:ad when considered in light of the supporting 
r; 
should be clarified to indicate that while 28 percent of the hospitals in the

survey sample reported the use of itinerant surgery, only seven hospitals (10

percent) used it extensively. These seven hospitals account for 134 of the

set.
177 itinerant surgery procedures included in the data 

RUR 
MANY  HOSPITALS SEE ITINERANT SURGERY AS A COST-EFFECTIVE MEANS OF 
RURL
PROVIDING NEEDED SURGERY waICH MIGHT NOT OTHERWISE BE AVAILABLE IN SOHE 

EAS 
FINDINGS  7) is supported by 
The discussion which follows this statement (
AH I S Section 
comments to the American Hospi tal Association by members of the 
for Small or Rural Hospitals. However, any study of rural health care options
environment,
needs to be a sensitive to the unique aspects of the rural 

particularly in these regions of the United States where access to health care

This
is affected by geography, weather or sparseness of the population. 

sensitivity could be maintained by using reviewers who are familiar with

practice patterns, resource and manpower constra1nts common in rural areas.

The report should also address the issue in a manner that reflects the full

context of rural health delivery.

Vbat would be the impact on the quality of rural medicine if itinerant

surgery' was not an option? 
What would be the impact on cost of care if patients could not be

treated in the rural setting?

Wht 
would be the individual social and economic impact if rural 
patients, particularly the rural elderly, needed to be transferred to 
commnity? 
hospitals outside the local 
CA 
HIGHR-THAVEGE RISK OF POOR QUALITY 
MEVETBELESS, THERE IS A 
IT15E 
SURGERY 
This statement (Findings , p. 8) raises questions as to the validity of

equati  re of the surgery, especially

poor quality with the itinerant 

81DCe the report statb. tbat no comparable data esists for a related

,opulation (i. e. surgical cases in small rural hospitals performed by local

surgeons) to determine if itinerant surgery alone accounts for adverse

outcomes ( Findings , p. 11).

quality' care. Poor
Tbe examples which are included cite instances of poor

defended. 
However, the report
quality care is inappropriate and should not be 
fashion. For 
does a poor job of presenting the findings in a belanced 
example, this discussion gives the impression, that there consistently was a 
surgery, 
higher than usual level of poor quality in hospitals using itinerant 
leaving buried in an appendix the fact that one-half of the 47 cases involving
providers. 
Furthermore it
poor quality occurred in only 2 of the 19 studied 

is unclear that the quality of care is a result of the itinerant nature of the 
practice. Poor quality care is unacceptable in any setting and should be 
credentialing, quality 
addressed by each hospital through appropriate 
assurance, and peer review. It is unfortunate, however, that on examples of 
thj s 
good quality care were cited in the report to give some perspective on 
ssue.  , (

OVERAL QUALITY OF CARE WAS SIGNIFICANTLY WORSE IN THESE CASES THAN IN A 
RAND SAMPLE OF SURGICAL CASES IN SMA RUR HOSPITALS 
We again maintain the inappropriateness of using an unrelated study as a basis 
of comparison, and question the validity of such comparisons when small 
numbers are translated into percentages (one case in thi ty . 3.3%) and 
compared under a nebulous heading such as Poor Quality Care or Good Quality 
Care. 
Qualifying statements are included within the text of the report, but are

ignored in making generalized statements of findings. Broad statements are

unsupported by the data which has been presented. Two examples follow:

Although not directly attributed to itinerant suraery, poor quality of

care occurred usually with the findings of no preoperative care, no post

operative care, and/or an adverse outcome with the itinerant surgery cases

in this inspection.  Findinas  p. 12) (emphasis added) 
itinerant suraery may result 
In summary, this comparison indicated that 

in poor quality of care delivered in hospitals that use itinerant 
surgeons. " Findings  p. 13) (emph8sis added) 
The section of the report dealing with findings about payment indicates the 
need for uniform coding requirements whch are &Down to participating
physicians, an  C08n 
the need to address a lack of  policy regarding post 
operative days or a.ounts covered by a global fee. 
UCOtHNDTIONS 
seu.ible. If a 
The recommendatioDS seem on the whole quite  hospital chooses 
an option whch broadeaa chice and meets the 
to provide itinerant surgery  a. 
needs of its cODstituents, that hospital has the responsibility to monitor the 
quality of care of those servces --in this case, consistent and within the 
-the provision of  servces within 
.cope of policies which govern  all surgical 
Amrican Hospital Association 
the iD8titution. The  fiDda the recommendations 
regarding iaple8ntation of 
procedures to ensure adequacy of preoperative 
vorkups, post operative care plans, and post oRerative commnication between 
the attending physician and the itinerant surgeon to be in concert with our 
Guidelines - Credentialing of Outreach Surgeons," which were distributed to

all AH .-mbers earlier 
this year (see Attachment A). 
The Hthodology PIOs will use- to review surgical procedures should be more 
clearly defined, and should be governed by criteria which take into account

the appropriate standards of medical practice and operational capabilities of
 , '
thin this 
rural hospitals of this size. The use of flawed methodology w 
reco.ndations for a 
survey also invalidates conclusions that result in 
These 
separate or distinct review of itinerant surgical procedures by PROs. 
any  surgical 
procedures should be reviewed within the same parameters as 
procedures performed within the hospital. In addition, methodological flaws

preclude any recommendation regarding second  hile patients should 
opinions. 
be made aware of such an option, it must be recognized that the option may not 
be locally available, particularly if the community needs to rely on itinerant 
surgeons. Patients who opt for local surgery may be unable to leave the 
community for a second opinion.

In addressing post operative 
care, it should be noted that complications are 
usually chronic medical conditions exacerbated by surgery and/ or anesthesia 
and are often more appropriately managed by internists, family practitioners

or subspecialists. Surgeons usually restrict themselves to managing problems

at the operative site.

The recommendation to recover overpayments is appropriate and the

recommendation to instruct carriers and participating physicians in the use of

propriate coding should help di.pel confusion 8Dd wisinformation about

billing procedures.

CONCLUS ION

The American Hospital Association is grateful for the opportunity to review 
its 
and comment on this draft report. Ve take no 8ianficant i.sue with 
reco8mendation8; however, we wish to state our coaern with the over.tat.-nt. 
in the findings whch are based on 8 8ethodolo(J which extrapolates a very 
narrow sample into broad statements of findings.

ow guidelines, the 
As evidenced by the development and issuance of our 
c08it 
American Hospital Association and its membercs0 a8rne ities. Iefd  to ensuring the 
availability of high quality care in rural  we can be of any 
Ioer 
(312/280-2) in 
further assistance, plea.e contact 5,1  our ChicalO 
office or Milton Dezube (202/638-2318) in our Vashiaaton Office.
 , ' ::'
li.. 
AlIc 
All.  ATTACHMENT A
Ho 
Guidelines 
Credentialg of 
Outreach Surgeons 
Thi6pidcline doment is inteded to proide generl advice to the membcip of the 
Amecan Hospital Assation. 
Intucon  rern 
blood use, emergency room  visits, 
and trsfer rates ar examples of clinical indica
For many ywar, soet in general and the health  tors that might be included in the reiew of the 
ca 
industry in particular hav ackowledged  surgeon s practice patterns. . 
that the delivery of medica ca must lIee the 
ommunity beng  The tys of produres appropriate for out
needs and desire of the 

while maintaining appropriate stndparrso ouf cnare .  reac surgery should be deterined, with board 
hospital 
In many rural areas eleaive surgcal  approal, by the medical stff and 
are performed by surgeons who commute frm  executive management. Considertion should be 
more populated areas. They maya desleg ate  to the degr of sophistication of thet seup
selec  sece, 
postopetive ca and  port  anesthesia capabilties, and 
preperative care to other physicians. Th pra  nolog available within the facility and the 
tice is often caled outrach swery. Whe done  expuse and exrience of the sucreao n, the 
appropriately, it proides a valuable and some anesetist, and the postopetive  givers. 
times necessary service that a community would 
Specific requirentS that relate to the outrach 
not otherwise have.

doct  surgery, such as raetntsdiibgili ty for case selection 
This  sotff ers gudacteh ro  hopspritoaso anrd  identication of  physicians for 
their medl  to asst  in  poopetive maagement, roqtine and emer
hi-qua medca an suca ca that  gecy orders, scpe of priviege, trnsfer pro 
SUns.  tool, etc., should be defined in the medca Stff 
be proided by outrach 
rensibil
rules and reations. The surgeon 
Guidelines  ties ro the medca Stff organizrion, such as 
committs, 
panc:pation on medical stff 
surcal 
Outreach sueons should be crentialed in the  shouJd be proportonal to the amount of 
meca  actvity performed by the surgeon at the
same manner as all otthher  apliScta ff members. 
ianuon  fo  intution. 
The  OD 
appontmt should be ve, an th shou 
be evaluated for reappoinnnent at leas evry  The outrac: surgeon shopulrdo be  included in the 
ywars. The clinical privileges granted to them  preperative asssment  and should be 
Should corrlate with their prerdevnciy  ptraaing  instrmental in the decsion rod oepetreartea. tTohne  soufr 
an  gen should pancipare in the 
should no exce me 
the prepertive testng needed for the patient, 
them at their primary institutions. Privieges 
evry tw  . and the rets of all testing should be available 
should be evaluated at lest  ywars and 
for reiew by the surgeon prior to surger. The 
should reflect an assessment of the practtioner 
experise and abilty. Morbidity and mortlity  patient should be fully informed of, understand, 
stdies, comparison of preperative and  and appro the conditions under which the 
produre wil be performed and the postopera. 
postoperative diagnoses, rehospitaliztion rare,
 tive ca proided. 
po 
.The pidelines do nOl conRiIruom a n AH Amon  our
Hosi.  The attding physician responsible for post
reac su  eon.. The)'  by rhe 
ta Assoation  Divilion of Medca AffaiR ro assist membe  operative care should be able to treat routine 
pitals with ourrach surger proams ro esablish insrru postoperative complications and be experienced 
rSional uprotorol gon crdeenriaoling annd qusality. assurance. The  in distinguishing which medical and surgcal

AH." reognizes that The praaice of outreac surgry is con. 
rroial and is, in fa, oppm by the America CoU. of omplications require transfer. This ph)'sician

This docment was dewloped at the request of the Amerca  intmded to aslist hospitals and their medical staffs in the 
Hanods hpaitsa l Assiation s SeC, ttihoanT f osre Somna sll  goro Rwuirnal  Hcoosutnacl,s   coruentrraiacl isnUg la'fntds .s uTbhsiesu ednotc maSeWnStl wmeanst  aopf pcarroe  pbly' 'tihdee Ad HbyA  
be appro 
th AHA Commincc on Hospital Medical Stafs. and the  Boar of TruStee on August " 1'88. 
AHA Institutional Pracices Commincc. The guidelines are 
a.." "'__ L I _L- L_- n...- ""L. .._-- III  , '

should be identified when the produre is  taken when warranted. The action may be a res
scheduled and should be available for the dura vocation of staff 
triction of pri\'ileges or 
tion of the hospital stay.
 appointment. Regardle!ls of the action taken, the 
uin  pro'edur  outlined in the medical 
fair he.
Explicit postoperative orders as well as operative  stff b)'laws must be followed. 
rens 
should be completed by the surgeon 
before leaving, and the surgeon should be avail Conclusion 
able by phone to consult on difficulties if the 
need arises. A mechanism for transferring  A hospital offeris:g outreach surgery is responsi
patients whose condition appears to require  ble for assuring that high quality i!l provided by 
resources not available at the hospital should be  outreach surgeons. Implementation of these 
in place and well understood by the hospital  guidelines, as a whole, wil help to promote 
staff.  high-quality outreach surgery. Credentialing and 
appropriate limits on clinical privileges, scrutiny 
The entire proces-assesment of preoperative  to determine what types of surgery are appropri
judgment, intraoperative skil, and postoperative  ate for an institution s outreach surgery program, 
management-should be included in the hospi and dearly-defined and well understood 
ta' s quality assurance program, and the findings  preperative and postoperative produres and

should be evaluated along with other faaors at
 requirements are all essential to assuring high-
the time of reappointment and privilege reiew.  quality outrach surgery services. 
An adverse findings should be evaluated by the 
medcal staff, and appropriate aaion should be  q " 
. '
1 ' 
AMERICAN ACADEMY OF FAMILY PHYSICIANS 
...0 WARO PARKWAV  KANSAS CITV.  MISSOURI 64114-2797 
O'''C' O' ,.. ",...,..,

JAMeS O. JONIS,
.'M".'..' O' '..,	 i!::.:;Vi
" .'.'CI...

.c..oo  O' .,.'C''''  r !!::;::.  :: CS-'UL

erriCE 
880." .....

.......". .C"A.'uO. ,'" 'N'O .UN,'.' 'C''A'''O'
'''
"'' ''''', .u.  1988 DEC 28 /,H S' 22 
December 23, 1988

RECE\VED 
Mr. Richard P. Kusserow,	
Inspector Geneeral row:
WashingHeatlothn & ,H uDmanC Se r2vic0es201J AN 06\989
Department  ot 
OF. R)t: 
OffICE 
\NSPECTOR GENE
Dear 
The American Academy of Family Physicians qreatly appreciates 
I s draft 
the opportunity to review and comment on y  r office 
report on "Itinerant Surqery"  Known as "Outreach Surgery"
to the Academy, it has been an issue  hat has received a 
considerable amount of attention and resources from the 
Academy in recent years. Included in Attachment A are a 
definition and policy of "outreach surgery" as approved by 
I s 
the Academy  Congress of Delegates in 1987. 
Academy staff has carefully reviewed your report and concurs 
that the results raise concerns regarding the qual i ty of
outreach surgery that require turther analysis and 
appropriate action.  extent 
of the
quality. problem in outTher Aecadaemcy qhue stisonus trheg  ery as reported in your study 
for the f9llowing reasons: 
(1)	 the small number of outreach surgical cases
reviewed; 
(2)	 the absence of a control group; 
(3 )	 the absence of criteria upon which medical judgments
regard  adequacy" and "
appropriateness" were
determined, and;

(4)	 the qualifications of the reviewers and whether they 
were true peers of those being reviewed. 
In the absence of an appropriate control, it is difficult to

ascertain whether the large number of adverse outcomes are

directly related to "itinerant surgery" or other physician,
hospital or patient factors. This deficienrcey sinu tlhet sst.u dy

requires additional stEdy to validate the 
states, in 
The Academy' s policy on peer review  part, that
clinical policies.n 
patient care should be established by
practicing physicians and based upon needs appropriate. to the
local area. Local circumstances and considerations such as  :. 
Letter to Mr. Kusserow

Page Two

December 23, 1988

those frequently found in inner city or rural areas may

modify final interpretations as to whether or not a standard

of care. is met.  The qualifications of the reviewers and the

selection of criteria upon which the medical judqments are

made should be made explicit in describing the peer review

process. 
In spite of these deficiencies in the study design, it i$

unlikely that all adverse outcomes are unrelated to 
deficiencies in the outreach surgery process. Protocols to 
assure quality care and optimal outcomes when outreach

surgery is performed should be instituted in 
all hospitals
where these services are performed. 
To that end, the Academy has encouraged and worked closely 
with the American Hospital Association to develop guidelines 
for "Credentialing of Outreach Surgeons" (see Attachment B).
The guidel ines address, and in some cases exceed, the
recommendations contained in your report to establish 
institutional protocols on credentialing and quality 
assurance for outreach surgery. The Academy actively
supports implementation of these guidelines which address 
credentialing and clinical privileges, selection of outreach 
surgical cases, and pre and postoperative protocols to assure 
high quality outreach surgery services. 
The Academy also agrees with and supports the 
need to clarify
proper coding, by all physicians involved, when outreach
surgery is performed. 
Uniform application of the "54" 
modifier by all carriers and education of physicians
regarding its proper use should be encouraged by 
HCFA.  I ' ,
oJ t 
Letter to Dr. Kusserow

Page Three
December 23 , 1988 
Again, thank you for the opportunity to comment on this

important report while still in its draft form. The

appropriate body within the Academy structure is meeting in

mid-January and it will further discuss the _draft report.

Any additional comments/suggestions will be forwarded to you

-- at the conclusion of that meeting. 
The Academy would welcome 
the opportunity to work with the appropriate individuals from 
your office in further studyinq the issue or designing 
programs to assure ongoinq access to high quality outreach 
surgery for Medicare beneficiaries. 
Sincerely, 
JAS!RG: dab 
tac.ents 
At  j: 
..-
.. . \! ',..   '%  "'''
'% 
I.,. 
102 
SUBSTANCE ABOSE (Continued) 
Treat.ent Proarams (Continued1 
st 
prc 
in whi 
le to  of the  the 
(b)  th  practices.

impaired physician 
proqrams providing treatment should:

(a) Be duly licensed, and

st 
physi 
th 
psy  st  af  and/or
t(hb) eMee  J
 oi CCf\"a,.cc.ci.ctni  en Aa:itation 'of Heathcae Orcanizations for
(in  withou impaiec physicias programs).
(1987) 
SURGERY 
2fce-
Based 
'a!ep ArtAJ :is  m favor orf seurge r peormed in thre ip hys;r-;JI,, s of.fii cor reter
w: 
da su  wen the paent'  wID net bec imstce,
0J  !h  *",';,a;r:,.   er thes 
m: 
 be  fo OIem  as wel as for profesioal 
th 

services. (1982)

r.ach - Definition

I'sis 
pcc: r-n Aaem r1 Fay  defines cucphc -scuvere a sc saur ger
physic:sueo  pi 
ph by a qeuJI't H ' ied  catu   twh her the  anaenrd 
of  c4ile  tahf  e pa'  ar proided by 
-1-+""  th  phys .i  physic. 
s fmWY  (1987) 
Outreachn - cPol icY

--s 
'I  AA  thn  ay.  aAata s.mc eat eton    ca retoe hreath
ca fe  '-U  af as  of 
cuchr u surger, facm=y ipsh ysAis san   exce 
ca  proide hinc qu:alatyt p reoperative and
l.v prac:  cucw:i ths tuheei:   an  teTh e AAFP
pss the  of  when  by a  of the
paf ay phys atne a  physSJeo, wi aprorite ccmmat
mes 
of  ca .bewee 
durinq each phase of surgical care
(pre-operative, intra-operative and post-operative). 
(1987)