a

GAO

United States General Accounting Office

Report to Congressional Committees

January 2004 MEDICARE

Payment Changes Are 

Needed for 

Assistants-at-Surgery

GAO-04-97
www.gao.gov/cgi-bin/getrpt?GAO-04-97.

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Highlights of GAO-04-97, a report to 

congressional committees 

January 2004

MEDICARE

Payment Changes Are Needed for 

Assistants-at-Surgery 

Members of a wide range of health professions serve as assistants-at-surgery, 

including physicians, residents in training for licensure or board certification 

in a physician specialty, several different kinds of nurses, and members of 

several other health professions. Hospitals employ all the types of 

nonphysician health professionals who perform the role. Hospital 

employees likely serve as assistants-at-surgery for a majority of the 

procedures for which the American College of Surgeons says an assistant is 

“almost always” necessary. The number of assistant-at-surgery services 

performed by physicians and paid under the Medicare physician fee 

schedule has declined, while the number of such services performed by 

nonphysician health professionals eligible to receive payment under the 

physician fee schedule has increased. 

There is no widely accepted set of uniform requirements for experience and 

education that the health professionals who serve as assistants-at-surgery 

are required to meet. The health professions whose members provide 

assistant-at-surgery services have varying educational requirements. No 

state licenses all the health professionals who serve as assistants-at-surgery. 

Furthermore, the certification programs developed by the various 

nonphysician health professional groups whose members assist at surgery 

differ. GAO found that there was insufficient information about the quality 

of care provided by assistants-at-surgery generally, or by a specific type of 

health professional, to assess the adequacy of the requirements for members 

of a particular profession to perform the role. 

There are three flaws in Medicare’s policies for paying assistants-at-surgery 

that prevent the payment system from meeting the program’s goals of 

making appropriate payment for medically necessary services by qualified 

providers. First, because Medicare pays for assistant-at-surgery services 

under both the hospital inpatient prospective payment system and the 

physician fee schedule, and hospital payments for surgical care are not 

adjusted when an assistant receives payment under the physician fee 

schedule, Medicare may be paying too much for some hospital surgical care. 

Second, paying a health professional under the physician fee schedule to be 

an assistant-at-surgery, instead of including this payment in an all-inclusive 

payment, gives neither the hospital nor surgeon an incentive to use an 

assistant only when one is medically necessary. Third, the distinctions 

between those health professionals eligible for payment as an assistant-atsurgery under the physician fee schedule and those who are not eligible are 

not based on surgical education or experience as an assistant. Criteria for 

determining who should be paid as assistants-at-surgery under the physician 

fee schedule do not exist. However, hospitals are responsible under health 

and safety rules to provide quality care for their patients. 

Medicare pays for assistant-atsurgery services under both the 

hospital inpatient prospective 

payment system and the physician 

fee schedule. Payments under the 

physician fee schedule are limited 

to a few health professions. In 

2001, Congress directed GAO to 

report on the potential impact on 

the Medicare program of allowing 

physician fee schedule payments to 

Certified Registered Nurse First 

Assistants for assistant-at-surgery 

services. This report examines: (1) 

who serves as an assistant-atsurgery, (2) whether health 

professionals who perform the role 

must meet a uniform set of 

professional requirements, and (3) 

whether Medicare’s payment 

policies for assistants-at-surgery 

are consistent with the goals of the 

program and, if not, whether there 

are alternatives that would help 

attain those goals. GAO analyzed 

information provided by physician 

and other health professional 

associations and Medicare payment 

data. 

GAO suggests that Congress may 

wish to consider consolidating all 

Medicare payments for assistant-atsurgery services under the hospital 

inpatient prospective payment 

system. CMS agreed that payment 

policy for assistants-at-surgery 

could be improved. 
Page i GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Letter 1

Results in Brief 3

Background 5

Various Health Professionals Provide Assistant-at-Surgery Services, 

and Hospital Employees Provide Most of These Services 9

Widely Accepted Professional Requirements for Assistants-atSurgery Do Not Exist 13

While Medicare Payments for Assistant-at-Surgery Services Have 

Flaws, Paying Hospitals for All These Services Would Correct 

Them 18

Conclusions 22

Matter for Congressional Consideration 22

Agency Comments 22

Appendix I Professional Associations, Schools, and Hospitals 25 

Appendix II Comments from the Centers for Medicare & 

Medicaid Services 27 

Tables 

Table 1: Physician Fee Schedule Payments for Health Professionals 

for Assistant-at-Surgery Services 8

Table 2: Health Professions Whose Members Can Assist at Surgery 10

Table 3: Education and State Licensure Requirements for Those 

Who May Assist at Surgery 14

Table 4: Surgical Education and Experience Requirements for 

Certification as an Assistant-at-Surgery 17

Figure 

Figure 1: Percentage of Assistant-at-Surgery Services Paid under 

the Physician Fee Schedule for Physicians and 

Nonphysician Health Professionals, 1997-2002 13

Contents 
Page ii GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Abbreviations 

ACS American College of Surgeons 

AHA American Hospital Association 

BBA Balanced Budget Act of 1997 

CMS Centers for Medicare & Medicaid Services 

CoP condition of participation 

CRNFA Certified Registered Nurse First Assistant 

GME graduate medical education 

HCFA Health Care Financing Administration 

PPS prospective payment system 

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Page 1 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

January 13, 2004 

Congressional Committees 

Ensuring that Medicare beneficiaries receive care from qualified providers 

and that payments to providers are for the appropriate amount and only 

for medically necessary services are recognized goals of Medicare. 

Achieving these goals when paying for assistants-at-surgery,1

 who perform 

tasks as members of surgical teams under the direction of surgeons, poses 

a particular challenge because of the range of considerations affecting 

whether hospitals or surgeons decide an assistant is necessary for a given 

beneficiary’s surgical procedure and the variation in education and 

experience of individuals who serve as assistants. 

Medicare pays hospitals, physicians, and certain nonphysician health 

professionals for assistant-at-surgery services through the hospital 

inpatient prospective payment system (PPS) and the Medicare physician 

fee schedule. Medicare makes a single payment to hospitals for all the 

services, including assistant-at-surgery services, that a hospital provides to 

a beneficiary while an inpatient. The inpatient PPS pays predetermined 

fixed amounts for groups, or bundles, of services, designed to provide 

incentives to control spending by rewarding efficiency. Medicare also pays 

teaching hospitals under the inpatient PPS for providing graduate medical 

education (GME) to the residents employed by the hospital, some of 

whom assist at surgery. 

Medicare also makes payments under the Medicare physician fee schedule 

for assistant-at-surgery services performed by physicians and members of 

certain nonphysician health professions whose members assist. These 

nonphysician health professionals—primarily physician assistants, nurse 

practitioners, and clinical nurse specialists—are allowed to bill Medicare 

under the physician fee schedule.2

 Congress has been asked to authorize 

 1

An assistant-at-surgery is sometimes referred to as a first assistant or second assistant. 

2

Members of a few other health professions, such as nurse midwives, can also be paid as 

assistants-at-surgery under the physician fee schedule. Assistant-at-surgery services 

performed by these professionals accounted for less than 1 percent of such Medicare-paid 

assistant services in 2002. When discussing payments for assistants-at-surgery under the 

physician fee schedule, this report focuses on physicians, physician assistants, nurse 

practitioners, and clinical nurse specialists. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Certified Registered Nurse First Assistants (CRNFA) and other 

nonphysician health professional groups whose members provide 

assistant-at-surgery services to bill Medicare under the physician fee 

schedule for these services. 

In 2001, Congress directed us to report on the potential impact on the 

Medicare program of allowing physician fee schedule payments to 

CRNFAs for assistant-at-surgery services.3

 Congress required that we give 

special consideration to quality of care, appropriate education 

requirements, and appropriate rates of Medicare payment for assistants-atsurgery. This report examines: (1) who serves as an assistant-at-surgery, 

(2) whether health professionals who perform the role must meet a 

uniform set of professional requirements, and (3) whether Medicare’s 

payment policies for assistants-at-surgery are consistent with the goals of 

the program and, if not, whether there are alternatives that would help 

attain those goals. 

To determine who serves as an assistant-at-surgery, we analyzed Medicare 

data for 1997 through 2002 from the Part B Extract and Summary System 

maintained by the Centers for Medicare & Medicaid Services (CMS),4

which oversees Medicare. These summary data are derived from the 

Medicare Physician/Supplier Procedure Summary Master Files, which 

contain procedure-specific billing data for all physician and supplier 

services provided to Medicare beneficiaries each year. CMS contractors 

edit these data, and data limitations are published annually. We used our 

analysis of these data to determine the number, variety, and location of 

surgical procedures for which physician and nonphysician health 

professional assistants-at-surgery sought Medicare payment under the 

physician fee schedule.5

 We also analyzed these data by the categories in 

the American College of Surgeons’ (ACS) study that classifies each 

 3

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Pub. L. 

No. 106-554, App. F, § 433, 114 Stat. 2763, 2763A-526. 

4

On July 1, 2001, the agency that administers the Medicare program was renamed from the 

Health Care Financing Administration (HCFA) to CMS. This report refers to the agency as 

HCFA when discussing actions taken before the name change and as CMS when discussing 

actions taken after the name change. 

5

Of the assistant-at-surgery services paid under the physician fee schedule in 2002, almost 

90 percent were for hospital inpatients, about 10 percent were for surgeries on hospital 

outpatients, and about 1 percent for surgeries in ambulatory surgical centers. Less than 

one-half of 1 percent of services allowed under the physician fee schedule for assistant-atsurgery services occurred in a nonfacility setting, such as a physician’s office. 
Page 3 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

surgical procedure by the likelihood that it will require an assistant-atsurgery.6

 We could not determine the number of assistants-at-surgery who 

were paid under the inpatient PPS because CMS does not collect those 

data. We interviewed staff from CMS; representatives of nine large 

academic teaching hospitals distributed across the country; and 

representatives of state licensing boards, assistant-at-surgery education 

programs, and associations of hospitals, physicians, nurses, and other 

health professions, including those whose members assist at surgery (see 

app. I). We used these interviews to determine whether nonphysician 

health professionals who perform the role of assistant-at-surgery must 

meet a uniform set of professional requirements. In making this 

determination, we also reviewed literature about the licensure and 

certification of health professionals who serve as assistants-at-surgery and 

Medicare laws and regulations affecting assistants. 

We conducted our work from July 2001 through December 2003 in 

accordance with generally accepted government auditing standards. 

Members of a wide range of health professions serve as assistants-atsurgery, including physicians, residents in training for licensure or board 

certification in a physician specialty, several different kinds of nurses, and 

members of several other health professions. Hospitals employ residents, 

international medical graduates,7

 and all the types of nonphysician health 

professionals who perform the role. Hospital employees likely serve as 

assistants-at-surgery for a majority of the procedures for which the ACS 

says an assistant is “almost always” necessary. Since 1997, the number of 

assistant-at-surgery services performed by physicians and paid under the 

Medicare physician fee schedule has declined, while the number of such 

services performed by nonphysician health professionals eligible to 

receive payment under the physician fee schedule has increased. 

 6

American College of Surgeons (ACS), Physicians as Assistants at Surgery: 2002 Study, 

4th edition (Chicago, Ill.: 2002). ACS members and members of 14 other surgical specialty 

organizations reviewed procedures applicable to their specialties and determined how 

often each surgical procedure requires the use of a physician as an assistant-at-surgery. 

7

International medical graduates are physicians who have graduated from a medical school 

outside the United States, Puerto Rico, or Canada. For purposes of this report, 

international medical graduates do not include individuals who are in U.S. residency 

programs or who are physicians licensed in the United States, but may include some who 

are certified as surgical assistants. 

Results in Brief 
Page 4 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

There is no widely accepted set of uniform requirements for experience 

and education that the health professionals who serve as assistants-atsurgery are required to meet. The health professions whose members 

provide assistant-at-surgery services have varying educational 

requirements. No state licenses all the health professionals who serve as 

assistants-at-surgery, and the health professional licenses that states do 

issue typically attest to the completion of broad-based health care 

education, rather than education or experience as an assistant. 

Furthermore, the certification programs developed by the various 

nonphysician health professional groups whose members assist at surgery 

differ. We found that there was insufficient information about the quality 

of care provided by assistants-at-surgery generally, or by a specific type of 

health professional, to assess the adequacy of the requirements for 

members of a particular profession to perform the role. 

There are three flaws in Medicare’s policies for paying assistants-atsurgery that prevent the payment system from meeting the program’s goals 

of making appropriate payment for medically necessary services by 

qualified providers. First, because Medicare pays for assistant-at-surgery 

services through both the hospital inpatient PPS and the physician fee 

schedule, and hospital payments for surgical care are not adjusted when 

an assistant receives payment under the physician fee schedule, Medicare 

may be paying too much for some hospital surgical care. Second, paying a 

health professional under the Medicare physician fee schedule to be an 

assistant-at-surgery, instead of including this payment in an all-inclusive 

payment, gives neither the hospital nor surgeon an incentive to use an 

assistant only when one is medically necessary. Third, the distinctions 

between those health professionals eligible for payment as an assistant-atsurgery under the physician fee schedule and those who are not eligible 

are not based on surgical education or experience as an assistant. Criteria 

for determining who should be paid as assistants-at-surgery under the 

physician fee schedule do not exist. However, hospitals are responsible 

under health and safety rules to provide quality care for their patients. 

To help address these flaws and meet Medicare’s goals, we suggest that 

Congress may wish to consider consolidating all Medicare payments for 

assistant-at-surgery services under the hospital inpatient prospective 

payment system. We received comments on a draft of this report from 

CMS, which agreed that payment policy for assistants-at-surgery could be 

improved. CMS also discussed several details related to implementing 

payment policy changes. 
Page 5 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Assistants-at-surgery, who serve as members of surgical teams, perform 

tasks under the direction of surgeons and aid them in conducting 

operations. These tasks may include making initial incisions (“opening”), 

exposing the surgical site (“retracting”), stemming blood flow 

(“hemostasis”), surgically removing veins and arteries to be used as bypass 

grafts (“harvesting”), reconnecting tissue (“suturing”), and completing the 

operation and reconnecting external tissue (“closing”). Some of these 

tasks, like retraction, are relatively simple, while others, such as 

harvesting, are more complex. An assistant-at-surgery may perform one or 

more simple or complex tasks during an operation. 

Tasks performed by others on the surgical team differ from those 

performed by assistants-at-surgery. Scrub staff work within the sterile 

field—the area within the operating room that is kept free from harmful 

microorganisms—passing instruments, sponges, and other items directly 

to the surgeon and assistant-at-surgery who work within the sterile field. 

Circulators work outside the sterile field, responding to the needs of team 

members within the sterile field. Anesthesiologists, or anesthetists, who 

administer and monitor anesthesia, painkillers, and other drugs, are also 

present during an operation. 

Decisions by a hospital or surgeon to use an assistant-at-surgery depend 

on the complexity of the operation and medical condition of the patient. 

Physician associations, such as the ACS and the American Society of 

General Surgeons, maintain that the surgeon should be responsible for 

determining if an assistant-at-surgery is needed, although some hospitals 

require the use of an assistant for certain surgical procedures. Hospitals 

that employ assistants-at-surgery may assign them to a procedure without 

consulting the surgeon performing the procedure. 

Since 1994, the ACS, with other surgical specialty organizations, has 

conducted studies to determine which surgical procedures require 

physicians as assistants-at-surgery. These studies classify surgical 

procedures as “almost always,” “sometimes,” or “almost never” requiring 

Background 

Need for Assistants-atSurgery Depends on 

Complexity of Operation, 

Condition of Patient 
Page 6 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

an assistant-at-surgery. The 2002 study classifies approximately 5,000 

surgical procedures, about 1,750 of which are designated as “almost 

always” requiring a physician to serve as an assistant-at-surgery.8

A small number of surgical procedures have accounted for the majority of 

the assistant-at-surgery services paid for under the Medicare physician fee 

schedule: In 2002, 100 procedures accounted for almost 75 percent of the 

assistant-at-surgery services that Medicare paid under the physician fee 

schedule. ACS designated 81 of these procedures as “almost always” 

requiring a physician as an assistant-at-surgery, and the remaining 19 

procedures were designated as “sometimes” requiring a physician as an 

assistant. 

Medicare pays for medically necessary services, including those 

performed by assistants-at-surgery, for eligible elderly and disabled 

patients provided by health professionals and institutions meeting certain 

requirements. Part A, or Hospital Insurance, pays for inpatient hospital 

care, care provided by certain other health care facilities, and some home 

health care. Part B, or Supplementary Medical Insurance, includes 

payment for the services and items provided by physicians, certain other 

nonphysician health professionals, suppliers, outpatient hospital 

departments, and home health care agencies. 

Medicare makes payments to hospitals under part A through the hospital 

inpatient PPS9

 for assistants-at-surgery.10 A fixed payment is made for all 

the inpatient hospital services, including assistant-at-surgery services, that 

a hospital provides to a beneficiary with a given diagnosis or receiving a 

particular type of surgery. Payments under the hospital inpatient PPS 

reflect the average bundle of services that beneficiaries with a particular 

 8

Approximately 1,550 surgical procedures are designated as “sometimes” requiring a 

physician as an assistant-at-surgery. In addition to procedures designated as “almost 

always” or “sometimes” requiring a physician to serve as an assistant-at-surgery, the 

remaining procedures are designated as “almost never” requiring a physician to serve as an 

assistant. 

9

42 U.S.C. § 1395ww (2000). 

10The bundle of services for which hospital inpatient payments are made generally does not 

include physician services provided by physicians, physician assistants, nurse 

practitioners, and clinical nurse specialists. 42 U.S.C. § 1395x(b)(4), (s)(2)(K) (2000). 

Medicare Pays for 

Assistants-at-Surgery as 

Part of PPS Payments to 

Hospitals and under the 

Physician Fee Schedule 
Page 7 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

diagnosis receive as inpatients in similar hospitals. The hospital’s payment 

for a bundle of services is the same regardless of whether an assistant-atsurgery is used or who provides the assistant-at-surgery services. 

Prospective payment systems, such as the hospital inpatient PPS, are 

designed to promote efficiency: because the payment for a particular 

bundle of services is almost always the same, regardless of the services a 

particular patient receives, hospitals are discouraged from providing 

unnecessary services.11 Providing additional services would not increase 

their payments. Consequently, PPS payments to the hospital are 

sometimes less and sometimes more than the cost of providing care. 

Payments are also made under the hospital inpatient PPS to teaching 

hospitals for providing GME to the residents employed by the hospital.12 In 

2001, about 20 percent of the approximately 5,800 U.S. hospitals were 

considered teaching hospitals. In 2003, surgical residents comprised about 

20 percent of all residents at these hospitals.13 There were about 7,500 

residents in general surgery and about 13,000 more surgical residents 

training for specialties, such as orthopedics, all of whom were required to 

serve as assistants-at-surgery as part of their training. In addition to these 

surgical residents, some nonsurgical residents have surgical rotations 

during which they serve as assistants-at-surgery. 

Medicare makes part B payments to assistants-at-surgery under the 

physician fee schedule14 when assistant services are performed by a 

physician or by a nonphysician health professional authorized to receive 

such payment. In 2002, these payments totaled about $158 million, less 

than 2 percent of the $10.5 billion Medicare paid to surgeons for surgical 

 11Additional payments are made for cases in which inpatient hospital care has been 

extraordinarily costly. About 7 percent of inpatient hospital PPS payments in fiscal year 

2002 were for these cases. 

12Teaching hospitals are paid an amount for each resident that covers the costs associated 

with providing services. 42 U.S.C. § 1395ww(h) (2000). 

13For purposes of this report, surgical residencies are defined as those in colon and rectal 

surgery, neurological surgery, obstetrics and gynecology, ophthalmology, orthopedic 

surgery, adult reconstructive orthopedics, foot and ankle orthopedics, hand surgery, 

musculoskeletal oncology, orthopedic sports medicine, orthopedic surgery of the spine, 

orthopedic trauma, pediatric orthopedics, otolaryngology, neurotology, pediatric 

otolaryngology, plastic surgery, craniofacial surgery, general surgery, pediatric surgery, 

surgical critical care, urology, pediatric urology, vascular surgery, and thoracic surgery. 

1442 U.S.C. § 1395w-4(a) (2000). 
Page 8 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

procedures that year. Medicare also makes global payments to surgeons 

under the physician fee schedule that cover the surgery and some pre- and 

postoperative services that the surgeons and their employees perform. 

Assistant-at-surgery services are not included in this bundle of services. 

Generally, the amount Medicare pays under the physician fee schedule is 

based on the resources needed to perform a service: the physician’s time 

and skill, practice expenses that include the costs of staff, equipment, and 

supplies, and the cost of liability insurance. While a surgeon’s global fee 

for a surgical procedure is set to reflect the resources required to perform 

the service, payments under the physician fee schedule for assistant-atsurgery services are not; they are calculated as a fixed percentage of the 

surgeon’s global fee. The percentage varies depending on the profession of 

the assistant-at-surgery. The Medicare physician fee schedule pays 

physicians more than nonphysician health professionals for assistant-atsurgery services (see table 1). 

Table 1: Physician Fee Schedule Payments for Health Professionals for Assistantat-Surgery Services 

Health profession Payment

Physician 16.0% of surgeon’s payment

Clinical nurse specialist 13.6% of surgeon’s payment

Nurse practitioner 13.6% of surgeon’s payment

Physician assistant 13.6% of surgeon’s payment

Source: 42 C.F.R. §§ 405.502(a)(9), 414.52, 414.56 (2002). 

Medicare sets requirements that various health care institutions, suppliers, 

and professionals must meet to be paid by the program. Institutions, such 

as hospitals, must meet conditions of participation (CoP)—health and 

safety rules used to ensure quality of care. Until 1986, HCFA specified 

some requirements for assistant-at-surgery services in its hospital CoP. 

Hospitals were required to have physicians serve as assistants-at-surgery 

for procedures “with unusual hazard to life,” while “nurses, aides, or 

technicians having sufficient training to properly and adequately assist’’ 

could assist at “lesser operations.”15 In a broad revision of the hospital CoP 

in 1986, the agency eliminated these requirements: it said the purpose of 

the revisions to the surgical services section, which had included the 

assistant-at-surgery requirements, was to “delete the overly prescriptive 

 1520 C.F.R. § 405.1031(a) (1967), redesignated as 42 C.F.R. § 405.1031(a) in 1977. 
Page 9 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

details” about the operation of surgical services.16 CMS retains 

requirements for other surgical team members, including scrub and 

circulating staff.17

CMS also establishes regulatory requirements for the health professions 

eligible to receive payment under the Medicare physician fee schedule. 

Members of that profession can be paid for providing covered services, 

including assistant-at-surgery services.18 Although CMS’s rules include the 

minimum requirements that these professionals must meet to receive 

payment for services, there are no specific requirements to receive 

assistant-at-surgery payments in Medicare regulations. General 

requirements include education, licensure, and certification; no surgical 

education or experience is mandated. For example, physician assistants 

must graduate from an accredited physician assistant education program, 

pass the National Commission on Certification of Physician Assistants 

certification examination, and be licensed to practice as a physician 

assistant, but do not have to have experience as an assistant-at-surgery. 

Members of a wide range of health professions serve as assistants-atsurgery. Hospitals employ residents, international medical graduates, and 

all the types of nonphysician health professionals who perform the role. 

Hospital employees likely serve as assistants-at-surgery for a majority of 

the procedures for which the ACS says an assistant is “almost always” 

necessary. The number of assistant-at-surgery services performed by 

physicians and paid for under the physician fee schedule has declined, 

while the number of such services performed by nonphysician health 

professionals eligible to receive payment under the physician fee schedule 

has increased. 

 16Medicare and Medicaid Programs; Conditions of Participation for Hospitals, 51 Fed. Reg. 

22010, 22027, 22042 (1986) (codified at 42 C.F.R. part 482). 

1742 C.F.R. § 482.51(a)(2), (3) (2002). 

1842 C.F.R. §§ 410.20(b), 410.74(c), 410.75(b), 410.76(b) (2002), rules for physicians, 

physician assistants, nurse practitioners, and clinical nurse specialists, respectively. 

Medicare may pay for any medically necessary service that an eligible health professional 

may perform under state law. 

Various Health 

Professionals Provide 

Assistant-at-Surgery 

Services, and Hospital 

Employees Provide 

Most of These 

Services 
Page 10 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Physicians, residents in training for licensure or board certification in a 

physician specialty, several different kinds of nurses, and members of 

several other health professions serve as assistants-at-surgery (see table 

2). Surgical associations state that surgeons or residents are preferred as 

assistants-at-surgery, but surgeons are often not available to assist at 

surgery. 

Table 2: Health Professions Whose Members Can Assist at Surgery 

Health profession Total number of membersa

Physician 

Physician (postresidency) 850,000

Resident 100,000

Nurse 

Registered nurse, including those in surgical 

specialties, such as orthopedics or plastic surgical 

nurses 3.1 millionb

Licensed practical/vocational nurse 900,000

Nurse practitioner 130,000c

Clinical nurse specialist 69,000c

Certified registered nurse first assistant 1,700

Other health professions 

Surgical technologist 71,000

Physician assistant 46,000

Ophthalmic assistant/technician/medical technologist 30,000-40,000

Surgical assistant 5,000-6,000

Orthopedic technologist 3,000

Orthopedic physician assistant 2,500

International medical graduate Unknown

Source: Health professional associations. 

a

Numbers are the most recent data available, typically for 2000. 

b

Includes nurse practitioners, clinical nurse specialists, and CRNFAs. The table also includes 

separate counts for each of these groups. 

c

The numbers for nurse practitioners and clinical nurse specialists include some nurses who have 

qualified as both. 

Members of a Variety of 

Health Professions Serve 

as Assistants-at-Surgery 
Page 11 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Hospitals employ the gamut of health professionals who serve as 

assistants-at-surgery to perform the role. Some hospitals tend to hire 

assistants-at-surgery from a particular health profession, sometimes 

offering training courses in assistant services for that profession, to ensure 

that the hospital has a sufficient number of assistants. To encourage 

surgeons to use their operating rooms, hospitals may (1) employ 

assistants-at-surgery, eliminating the need for the surgeons to hire their 

own assistants, or (2) arrange for health professionals in independent 

practice to serve as assistants. 

While teaching hospitals use residents as assistants-at-surgery, these 

hospitals may also hire nonphysician health professionals to perform the 

role. In a recent survey of neurosurgery residency program directors, 

nearly all cited the need to hire nonphysician health professional staff, 

such as physician assistants, in response to the weekly 80-hour work limit 

for residents.19 Teaching hospitals with other surgical specialty programs 

may also need to hire nonphysician health professionals as assistants-atsurgery because of the limit on resident hours. 

Because hospitals are not required to keep records on the use of 

assistants-at-surgery to receive Medicare payment under the inpatient PPS, 

the number and cost of such services provided by all hospital employees 

are unknown. Still, hospital employees likely serve as assistants-at-surgery 

for the majority of the surgeries performed on Medicare patients. In 2002, 

Medicare made payments under the physician fee schedule to assistantsat-surgery about 36 percent of the time that the program made payments 

to surgeons for the surgical procedures that ACS designated in its most 

recent study as “almost always” requiring an assistant-at-surgery.20 Since 

the remaining 64 percent of those surgical procedures were likely to have 

had assistants-at-surgery, hospital employees would likely have performed 

this role. In its final regulation revising the physician fee schedule for 2000, 

 19Dongwoo John Chang, M.D., and Susan Bell, R.N., “Restricted: The Impact of Residents’ 

80-Hour Workweek on Neurosurgical Resident Training and Patient Care,” American 

Association of Neurological Surgeons Bulletin: The Socioeconomic and Professional 

Quarterly for AANS Members, 12:2:7-10 (2003). 

20In 2002, about 75 percent of these Medicare-paid services for assistants-at-surgery were 

for surgical procedures determined by ACS as “almost always” requiring a physician as an 

assistant, about 24 percent for procedures ACS determined to “sometimes” require an 

assistant, and the remaining payments were for procedures determined as “almost never” 

requiring an assistant or for surgical procedures with no designation. 

Hospitals Employ the Full 

Range of Health 

Professions Whose 

Members Serve as 

Assistants-at-Surgery 

Hospital Employees Likely 

Perform More than Half of 

All Assistant-at-Surgery 

Services 
Page 12 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

HCFA relied upon the results of the American Hospital Association’s 

(AHA) National Hospital Panel Survey that found that only 11 percent of 

responding hospitals said it was a regular practice for physicians to bring 

their own staff to the hospital to serve as assistants-at-surgery or to 

perform other functions.21 A representative of the AHA told us that most 

assistants-at-surgery, including residents and nonphysician staff, are 

hospital employees. 

The percentage of assistant-at-surgery services paid to physicians under 

the physician fee schedule has declined, and the percentage of these 

services paid to nonphysician health professionals has increased, 

particularly since enactment of the Balanced Budget Act of 1997 (BBA). 

The act raised the amount paid for assistant-at-surgery services to these 

nonphysician health professionals under the physician fee schedule, 

extended billing by clinical nurse specialists and nurse practitioners to 

urban areas (such billing had been limited to rural areas), and allowed 

physician assistants to contract with surgeons to be an assistant without 

having to be employees of the surgeon.22 The number of assistant-atsurgery services paid for under the physician fee schedule and provided by 

nonphysician health professionals increased more than 200 percent from 

1997 through 2002, while the number of services provided by physicians 

serving as assistants declined about 23 percent.23 During this period, the 

percentage of Medicare-paid assistant-at-surgery services performed by 

nonphysician health professionals increased by 25 percentage points (see 

fig. 1). 

The amount paid to nonphysicians for these services has also increased. 

Prior to 1987, nonphysicians could not be paid as assistants-at-surgery. In 

1997, nonphysicians were paid only $16 million for assistant-at-surgery 

services; in 2002, they were paid about $54 million. In comparison, 

physicians were paid $295 million for assistant-at-surgery services in 1986; 

$166 million in 1997; and $104 million in 2002. 

 21Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for 

Calendar Year 2000, 64 Fed. Reg. 59401 (1999). 

22Pub.L.No. 105-33, §§ 4511-4512, 111 Stat. 251, 442-443. These provisions apply to services 

performed after 1997. 

23In 1997, Medicare paid 1,246,817 assistant-at-surgery services, 1,100,919 of which were 

provided by physicians. In 2002, Medicare paid 1,356,244 assistant-at-surgery services, 

848,314 of which were provided by physicians. 

Nonphysicians Are 

Performing an Increased 

Share of Assistant-atSurgery Services Paid 

under the Physician Fee 

Schedule 
Page 13 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Figure 1: Percentage of Assistant-at-Surgery Services Paid under the Physician Fee 

Schedule for Physicians and Nonphysician Health Professionals, 1997-2002 

There is no widely accepted set of standards for the education and 

experience required to serve as an assistant-at-surgery. The health care 

professions whose members provide assistant-at-surgery services have 

varying educational requirements. No state licenses all the types of health 

professionals who serve as assistants-at-surgery. And the licenses they 

issue typically attest to the completion of broad-based health care 

education, making them of limited value in determining which health 

professionals have the education and experience to serve as an assistantat-surgery. Furthermore, the certification programs developed by the 

various nonphysician health professional groups whose members assist at 

surgery differ. We found that there was insufficient information about the 

quality of care provided by assistants-at-surgery—either generally or by 

members of specific health professions—to assess the adequacy of the 

requirements for a particular profession. 

Widely Accepted 

Professional 

Requirements for 

Assistants-at-Surgery 

Do Not Exist 

0

20

40

60

80

100

1997 1998 1999 2000 2001 2002

Physicians

Nonphysicians

Percentage

Source: GAO.
Page 14 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

The health professions whose members serve as assistants-at-surgery have 

varying educational requirements (see table 3). For example, a licensed 

practical nurse typically completes a 1-year educational program, while a 

clinical nurse specialist must have a master’s of science degree in nursing. 

In some cases, experience can substitute for education: orthopedic 

physician assistants may have associate degrees or certificates from 

military or nondegree programs or 5 years of experience working for an 

orthopedic surgeon. 

Table 3: Education and State Licensure Requirements for Those Who May Assist at Surgery 

Health profession General education requirements 

Licensure requirements 

in all states 

Physician 

Physician (postresidency) Doctor of medicine or osteopathy Yes 

Resident Doctor of medicine or osteopathy Yesa

Nurse 

Registered nurse, including those in 

surgical specialties, such as orthopedics 

and plastic surgical nurses 

Associate’s or bachelor’s degree in nursing or nondegree 

hospital diploma 

Yes 

Licensed practical/vocational nurse 1-year program Yes 

Nurse practitioner Master’s of science in nursing or nondegree certificate Yesb

Clinical nurse specialist Master’s of science in nursing Yesb

Certified registered nurse first assistant Bachelor’s degree and certification program Yes 

Other health professions 

Surgical technologist Associate’s degree, military or nondegree certificate Noc

Physician assistant Associate’s or bachelor’s degree or nondegree certificate Yes 

Ophthalmic assistant/technician/medical 

technologist 

Certificate programs or work experience No 

Surgical assistant Bachelor’s degree or nondegree certificated Noe

Orthopedic technologist 1-year certificate program, 2 years of experience, or 

combination 

No 

Orthopedic physician assistant Associate’s degree, military or nondegree certificate, or 

5 years of experience 

Nof

International medical graduate Non-U.S. degree in medicine No 

Source: Health professional associations. 

a

Residents typically become licensed during their residency training. 

b

Some states require an additional license as an advanced practice nurse. 

Health Professions Whose 

Members Assist at Surgery 

Have Varying Educational 

Requirements 
Page 15 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

c

Only two states have laws that regulate this profession: Texas established a licensure program in 

2001 for “licensed surgical assistants,” and beginning July 1, 2004, surgical technologists are 

required to meet registration requirements to practice in Illinois (2003 Ill. Laws 93-0280, adding 

225 Ill. Stat. 130/1 – 130/170). 

d

Some international medical graduates who have not obtained a residency or qualified for a license 

choose to become certified as surgical assistants. 

e

Only two states have laws that regulate this profession: Texas established a licensure program in 

2001 for “licensed surgical assistants,” and beginning July 1, 2004, surgical assistants are required to 

meet registration requirements to practice in Illinois (2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 

130/1 – 130/170). 

f

Licensure is required in Tennessee (Tenn. Code Ann. § 63-19-202 (2003)) and New York (N.Y. Educ. 

§§ 6540 – 6548 (2001)). In California, some orthopedic physician assistants who were licensed as 

physician assistants have been grandfathered in as physician assistants. 

While state licenses for health professionals, including those eligible for 

payment as assistants-at-surgery under the physician fee schedule, 

typically have “scopes of practice” that include assistant-at-surgery 

services, education and experience as an assistant are not necessarily 

required to obtain a license: the licenses for these health professions attest 

to the completion of broad-based health care education, which may not 

include courses in surgery. 

No state licenses all the health professions whose members assist at 

surgery in its jurisdiction. For example, orthopedic physician assistants 

and surgical assistants are licensed in only a few states. Only one state, 

Texas, has a specific assistant-at-surgery license. Members of different 

health professions may qualify for this license, which requires surgical 

education and experience.24 Nevertheless, a license is not required to serve 

as an assistant-at-surgery in Texas. 

Certification programs for assistants-at-surgery generally require 

completion of a certain level of education or experience and passage of an 

examination. Each certification program created by a group of 

nonphysician health professionals for its members who serve as 

assistants-at-surgery has different requirements (see table 4). Certification 

programs for some nonphysician health professions not eligible for 

 24Effective September 2001, Texas established a license category for “licensed surgical 

assistants.” (Texas Acts 2001 Tex. Gen. Laws ch. 1014, adding Tex. Occupations Code Ann., 

ch. 206.) Licensure requirements include 2,000 hours of experience, completion of a 

surgical training program with courses in specified areas such as anatomy and aseptic 

technique, an associate’s degree, and certification by a national organization recognized by 

the Texas State Board of Medical Examiners. 

State Licenses Typically 

Do Not Require Education 

and Experience as 

Assistants-at-Surgery 

Nonphysician Health 

Professions’ Certification 

Programs for Assistants-atSurgery Vary 
Page 16 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

payment under the physician fee schedule are for a wide range of surgical 

services; others are specific to a particular type of surgery. For example, a 

CRNFA, in addition to being licensed as a registered nurse and earning a 

bachelor’s degree in nursing,25 must obtain certification as an operating 

room nurse, complete an approved program, have 2,000 hours of 

experience as an assistant-at-surgery, and pass an examination. For a 

surgical technologist to receive certification as an assistant-at-surgery, 

he/she must have a surgical technologist certification, complete an 

approved program or have 2 years of experience as an assistant, and pass 

the examination. 

Certifications for those who are eligible for payment under the physician 

fee schedule as an assistant-at-surgery are typically for a broad range of 

services and are not specifically surgery-related. For example, the 

American Nurses Credentialing Center awards certifications to nurse 

practitioners for acute, adult, family, gerontological, pediatric, adult 

psychiatric and mental health, and family psychiatric and mental health 

care. 

 25As of January 1, 2000, only registered nurses who have a bachelor’s degree in nursing can 

be newly certified as CRNFAs. In 2002, less than 20 percent of CRNFAs had such a degree. 
Page 17 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Table 4: Surgical Education and Experience Requirements for Certification as an Assistant-at-Surgery 

Health profession Surgical education requirements for certification 

Surgical experience requirements for 

certification 

Nurse 

Registered nurse, surgery-related 

certificationa

Requirements vary by certification program, but 

surgical education is not required for certain surgicalrelated certifications 

Requirements vary by certification 

program, but surgical experience is not 

required for certain surgical-related 

certifications 

Certified registered nurse first 

assistant 

Two to three surgical classes 2,400 hours of operating room 

experience in the scrub or circulating role 

and 2,000 hours as assistant-at-surgery 

Other health professions 

Surgical assistantb Completion of an approved surgical assistant 

education program or an international medical 

education program, unless surgical experience is 

substituted 

2 to 3 years of surgical assistant 

experience, depending on certification 

program 

Orthopedic physician assistantc Three permissible educational paths for certification: 

completion of an orthopedic physician assistant 

program that includes surgical education; a primary 

care physician assistant program that may have 

minimal surgical education; and a nurse practitioner 

program that may or may not include surgical 

education, unless surgical experience is substituted 

5 years of experience that includes 

surgical assisting 

Surgical technologistd Completion of an approved surgical education 

program that includes instruction and supervised 

surgical experience, unless surgical experience is 

substituted 

2 years of surgical experience 

Orthopedic technologiste Completion of an approved surgical education 

program that includes an operating room rotation, 

unless surgical experience is substituted 

1 year of surgical experience 

Ophthalmic assistant/ 

technician/medical technologistf

Completion of an approved education program that 

includes instruction and supervised surgical 

experience, unless surgical experience is substituted 

18 months of surgical experience 

Source: Health professional associations. 

a

A variety of surgery-related certifications are available to registered nurses. Some of these are for 

surgical specialties, such as orthopedic nurse certified (ONC) or certified plastic surgical nursing 

(CPSN). While the ONC requires 1,000 hours of experience as an orthopedic nurse and the CPSN 

requires 2 years’ experience of plastic surgical nursing, both of which may include operating room 

experience, neither program requires operating room experience. 

b

Certified Surgical Assistant (CSA), Surgical Assistant-Certified (SA-C). 

c

Orthopedic Physician’s Assistant, Certified (OPA-C). 

d

Certified Surgical Assistant/Certified First Assistant (CST/CFA). 

e

Orthopedic Technologist-Surgery Certified (OT-SC). 

f

Certified Ophthalmic Assistant (COA), Technician (COT), or Medical Technologist (COMT)-

Ophthalmic Surgical Assisting. 
Page 18 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

While some national physician and accreditation organizations say 

assistants-at-surgery should have to meet some requirements, there is no 

consensus about what those requirements should be. For example, ACS 

has stated that when surgeons or residents are unavailable to serve as 

assistants-at-surgery, nonphysician health professionals should be allowed 

to perform the role if they meet the “national standards” for their health 

profession or have “additional specialized training.” Similarly, the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO), a 

private organization that accredits health care organizations, including 

hospitals, requires hospitals to credential their staff (i.e., establish 

requirements, such as licensure, certification, and experience for 

physicians and certain nonphysician health professionals) and ensure that 

those requirements are used when personnel decisions are made. But 

JCAHO does not suggest the type or length of education or experience to 

be used in credentialing hospital staff who serve as assistants-at-surgery. 

We found little evidence about the quality of care provided by assistantsat-surgery. Our February 2003 search of relevant literature maintained by 

the National Library of Medicine found only six articles dealing with the 

quality of care provided by assistants-at-surgery. None of the articles 

compares the quality of assistant-at-surgery services provided by one 

nonphysician health profession with that provided by another 

nonphysician health profession or physicians, and only one deals 

specifically with the influence of assistants on surgical outcomes. 

There are three flaws in Medicare’s policies for paying assistants-atsurgery that prevent the payment system from meeting the program’s goals 

of making appropriate payment for medically necessary services by 

qualified providers. First, because Medicare pays for assistant-at-surgery 

services under both the hospital inpatient PPS and the physician fee 

schedule, and hospital payments for surgical care are not adjusted when 

an assistant receives payment under the physician fee schedule, Medicare 

may be paying too much for some hospital surgical care. Second, paying a 

health professional under the Medicare physician fee schedule to be an 

assistant-at-surgery, instead of including this payment in an all-inclusive 

payment, gives neither the hospital nor the surgeon an incentive to use an 

assistant only when one is medically necessary. Third, the distinctions 

between those health professionals eligible for payment as an assistant-atsurgery under the physician fee schedule and those who are not eligible 

No National Consensus on 

Requirements for 

Assistants-at-Surgery 

Exists 

Literature on Assistants-atSurgery Is Insufficient to 

Evaluate Quality of Care 

While Medicare 

Payments for 

Assistant-at-Surgery 

Services Have Flaws, 

Paying Hospitals for 

All These Services 

Would Correct Them 
Page 19 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

are not based on surgical education or experience as an assistant. Criteria 

for determining who should be paid as assistants-at-surgery under the 

physician fee schedule do not exist. However, hospitals are responsible 

under health and safety rules to provide quality care for their patients. 

Medicare’s policy of paying hospitals for the services associated with 

inpatient surgical care that may include assistant-at-surgery services and 

also paying physicians and certain nonphysician health professionals for 

those services is flawed. When Medicare pays under the hospital inpatient 

PPS and under the physician fee schedule for assistant-at-surgery services 

delivered to a particular patient, Medicare may pay too much for the 

assistant services because the hospital is not paid less when the assistant 

receives payment under the physician fee schedule. In addition, a hospital 

that uses an assistant-at-surgery who is eligible for payment under the 

physician fee schedule has a financial advantage in the form of lower labor 

costs over a hospital that uses assistants who cannot be paid under the 

physician fee schedule. 

Given the discretion that hospitals and surgeons have in determining when 

and how an assistant-at-surgery is used, it is especially important that 

Medicare’s payment policy create incentives to help ensure that assistant 

services are provided for Medicare patients only when medically 

necessary.26 Allowing physician fee schedule payments to certain 

assistants-at-surgery, however, creates an incentive for hospitals to use 

them, rather than those who cannot be paid under the fee schedule. 

Because neither the hospital nor the surgeon incurs a cost when an 

assistant-at-surgery is paid under the physician fee schedule, neither has a 

financial incentive to use an assistant only when one is necessary. The 

lack of this incentive is of concern because assistant-at-surgery services 

receive little review to determine the medical necessity of the services. A 

2001 report by the Department of Health and Human Services Office of 

Inspector General27 found that most contractors used by Medicare to pay 

for part B services do not have any mechanism to ensure that assistant-atsurgery requests for payment for nonphysician health professionals are 

 26No Medicare payment may be made for any expenses incurred for items or services that 

“are not reasonable and necessary for the diagnosis or treatment of illness or injury....” 42 

U.S.C. § 1395y(a)(1)(A) (2000). 

27Department of Health and Human Services, Office of Inspector General, Medicare 

Coverage of Non-Physician Practitioner Services, OEI-02-00-00290, June 2001. 

Medicare Payments for 

Assistants-at-Surgery Are 

Flawed 
Page 20 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

reviewed for medical necessity before they are paid. Medicare routinely 

requires submission of documentation of medical necessity for medical 

review for only 1 percent of assistant-at-surgery services paid under the 

physician fee schedule. 

Because the requirements for those authorized to be paid as assistants-atsurgery under the Medicare physician fee schedule do not include 

assistant-at-surgery education or experience, payments can be made to 

assistants with no such education or experience. For example, about 23 

percent of physician assistants work in surgical specialties. Other 

physician assistants working in nonsurgical specialties, however, may be 

paid as assistants-at-surgery under the Medicare physician fee schedule, 

and their only surgical experience may be a 6-week surgical rotation. On 

the other hand, nonphysician health professionals, such as surgical 

technologists, CRNFAs, and orthopedic physician assistants, all of whom 

have certification programs requiring education and experience as an 

assistant-at-surgery, cannot be paid by Medicare for their services under 

the physician fee schedule. 

One way to address a concern associated with the physician fee schedule 

payments for assistants-at-surgery is to expand the number of 

nonphysician health professions eligible for payment. But this would not 

ensure that only those with the appropriate education and experience 

serve as assistants-at-surgery unless CMS also sets standards for all those 

who serve as assistants. There is no consensus, however, on what such 

standards should include. 

Bundling all payments for assistants-at-surgery into either the inpatient 

hospital PPS or the surgeon’s global fee would address the flaws of the 

current payment system. The possibility of paying too much for assistantat-surgery services would be eliminated because Medicare would make 

only one payment—to either the hospital or the surgeon—for the service. 

The hospital or surgeon would have a financial incentive to use the most 

appropriate assistant-at-surgery—and to use one only when necessary—

because the payment would be the same regardless of whether an 

assistant was used. The lack of a relationship between the nonphysician 

health professionals eligible for assistant-at-surgery payments under the 

physician fee schedule and their education and experience would be moot 

because payments would no longer be made to individuals performing the 

Bundling Payments for 

Assistant-at-Surgery 

Services into Hospital 

Payments Would Be 

Preferable to Bundling into 

Surgeons’ Fees 
Page 21 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

role; payments would be made, as part of a larger payment for a bundle of 

services, to hospitals or surgeons, who would have the responsibility to 

determine the education and experience that an assistant-at-surgery needs 

and when an assistant is needed. 

Folding payments for assistant-at-surgery services into inpatient PPS 

payments has some advantages that would not accrue if payments were 

folded into the surgeon’s global fee. Hospitals would continue to have 

incentives to use assistants-at-surgery when they are necessary, and to use 

the most appropriate assistant. Hospitals are already responsible—under 

the hospital CoP—for ensuring the health and safety of their patients and 

that necessary services are provided, including assistant-at-surgery 

services. Most hospitals already have credentialing processes for their 

employees. Also, since hospitals likely employ most assistants-at-surgery, 

limiting payments for assistant services to those made under the inpatient 

PPS would disrupt the employment relationships for far fewer assistants 

than would be the case if payment was made to surgeons. 

There is precedent for Congress approving legislation that no longer 

allows a service to be paid for separately under part B, but instead 

requires that the service be included in a bundle of services under part A. 

In 1997, Congress passed legislation that requires virtually all kinds of 

services or items furnished to beneficiaries residing in skilled nursing 

facilities (SNF) that had been paid for separately under part B, instead be 

included in a bundle of services paid for under part A.28 Prior to 

implementation of the provision, SNFs could permit a nonphysician health 

professional or supplier to seek payment under part B for ancillary 

services or items furnished directly to SNF residents, as long as the SNF 

did not include the service or item in its part A bill. The legislation, 

however, prevents this “unbundling” by including in Medicare SNF PPS 

payments ancillary services or items a SNF resident may require that 

previously had been paid under part B. 

Bundling assistant-at-surgery services into the package of services covered 

by the surgeon’s global payment based on the Medicare physician fee 

schedule has significant drawbacks. First, because the amount paid under 

the inpatient hospital PPS for assistants-at-surgery is unknown, the total 

amount to be added to the physician fee schedule for providing assistants 

is unknown. Second, a payment amount for assistant-at-surgery services 

 28BBA, § 4432, 111 Stat. 414. 
Page 22 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

would have to be determined for each surgical procedure. Since data are 

not collected on how often each surgeon uses assistants-at-surgery for 

each surgical procedure, the bundled payment would presumably include 

an allotment for the expected average cost of assistants for all surgeons 

performing the procedure. Using this approach, surgeons with an 

unusually high number of procedures requiring assistants would be paid 

too little, while those with an unusually low number of procedures 

requiring assistants would be paid too much. In addition, a surgeon would 

have a financial incentive to use an assistant-at-surgery less frequently for 

surgical procedures for which ACS says that an assistant may be needed, 

even when the condition of the beneficiary indicates that an assistant 

would be desirable. Because there is a difference in costs to a surgeon 

depending on whether an assistant-at-surgery is used, a surgeon’s bundled 

payment amount could be adjusted when an assistant is used. Doing so, 

however, would provide no financial incentive for surgeons to use an 

assistant-at-surgery only when one is medically necessary. 

Decisions to use an assistant-at-surgery should not be influenced by 

payment; they should be based on medical necessity. The majority of 

assistants-at-surgery are likely employed by hospitals, where the inpatient 

hospital PPS pays for their services. If Congress were to consolidate 

Medicare physician fee schedule payments for assistant-at-surgery 

services into the inpatient hospital PPS, this would give hospitals an 

incentive to use assistants only when they are necessary. Meanwhile, the 

hospital CoP would continue to give hospitals an incentive to assure that 

the most appropriate assistants-at-surgery are used as part of their 

responsibility to provide quality care for their patients. Paying for 

assistants under the physician fee schedule provides no such incentive. 

We suggest that Congress may wish to consider consolidating all Medicare 

payments for assistant-at-surgery services under the hospital inpatient 

prospective payment system. 

We received comments on a draft of this report from CMS, which agreed 

that payment policy for assistants-at-surgery could be improved. CMS 

noted that it would be helpful to describe the ongoing review process that 

CMS uses to assign relative values to physician fee schedule services. 

However, as we state in this report assistants-at-surgery are not paid on 

the basis of the resources they use to perform their work, but are instead 

Conclusions 

Matter for 

Congressional 

Consideration 

Agency Comments 
Page 23 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

paid a percentage of the amount paid the surgeon. CMS also discussed 

several details related to implementing payment changes for assistants-atsurgery. Addressing these points was beyond the scope of this report. 

CMS’s comments appear in appendix II. In addition, we obtained oral 

comments on a draft of this report from representatives of the American 

Medical Association, the American College of Surgeons, the American 

Society of General Surgeons, the American Association of Orthopaedic 

Surgeons, the Society of Thoracic Surgeons, the American Academy of 

Nurse Practitioners, the American Academy of Physician Assistants, the 

Association of periOperative Registered Nurses, and the American 

Hospital Association. We have modified the report, as appropriate, in 

response to their comments. 

We are sending copies of this report to the Acting Administrator of CMS, 

appropriate congressional committees, and other interested parties. We 

will also make copies available to others upon request. This report will be 

available at no charge on GAO’s Web site at http://www.gao.gov. 

If you or your staffs have any questions about this report, please call me at 

(202) 512-7101. Lisanne Bradley and Michael Rose were major 

contributors to this report. 

Marjorie Kanof 

Director, Health Care—Clinical Health Care Issues 
Page 24 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

List of Committees 

The Honorable Charles E. Grassley 

Chairman 

The Honorable Max Baucus 

Ranking Minority Member 

Committee on Finance 

United States Senate 

The Honorable W.J. “Billy” Tauzin 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Bill Thomas 

Chairman 

The Honorable Charles B. Rangel 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 
Appendix I: Professional Associations, 

Schools, and Hospitals 

Page 25 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

To obtain information about assistants-at-surgery and their services we 

contacted subject matter experts. We interviewed representatives of: 

American Academy of Nurse Practitioners 

American Academy of Physician Assistants 

American Association of Orthopaedic Surgeons 

American Board of Surgical Assistants 

American College of Surgeons 

American Hospital Association 

American Medical Association 

American Nurses Association 

American Nurses Credentialing Center 

American Society of General Surgeons 

American Society of Plastic Surgical Nurses 

Anne Arundel Community College, Department of Nursing 

Association of periOperative Registered Nurses 

Association of Surgical Technologists 

BJC HealthCare 

Centers for Medicare & Medicaid Services 

Certification Board Perioperative Nursing 

Commission on Accreditation of Allied Health Education Programs 

Duke University Hospital 

Educational Commission for Foreign Medical Graduates 

Ft. Sam Houston, Academy of Health Sciences, U.S. Army 

Inova Fairfax Hospital 

Johns Hopkins University, School of Medicine 

Joint Commission on Allied Health Personnel in Ophthalmology 

Massachusetts General Hospital 

Mayo Clinic 

Medical Group Management Association 

Montgomery College Surgical Technology Program 

National Association of Clinical Nurse Specialists 

National Association of Orthopaedic Nurses 

National Board for Certification of Orthopaedic Technologists 

National Commission for Certifying Agencies/National Organization for 

Competency Assurance 

National Rural Health Association 

National Surgical Assistant Association 

Naval School of Health Sciences 

New York State Board for Medicine 

Office of the Surgeon General of the Air Force 

Office of the Chief, Medical Corps, U.S. Navy 

Stanford University Hospital 

Appendix I: Professional Associations, 

Schools, and Hospitals 
Appendix I: Professional Associations, 

Schools, and Hospitals 

Page 26 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Texas State Board of Medical Examiners 

The American Society of Orthopaedic Physician’s Assistants 

The Cleveland Clinic 

The Society of Thoracic Surgeons 

University of California at Los Angeles School of Nursing 

University of Maryland School of Nursing 

University of Michigan Hospital 

University of Washington Medical Center 
Appendix II: Comments from the Centers for 

Medicare & Medicaid Services 

Page 27 GAO-04-97 Medicare Payments for Assistants-at-Surgery 

Appendix II: Comments from the Centers for 

Medicare & Medicaid Services 
Appendix II: Comments from the Centers for 

Medicare & Medicaid Services 

Page 28 GAO-04-97 Medicare Payments for Assistants-at-Surgery (290067) 
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