EMERGENCY ROOM COVERAGE:

WHAT EVERY NEUROSURGEON

SHOULD KNOW

Section on Neurotrauma and Critical Care

 SECTION ON NEUROTRAUMA
AND CRITICAL CARE
HEAD INJURY SPINAL CORD INJURY SPORTS MEDICINE CRITICAL CARE PREVENTION

A Section of the
American Association of Neurological Surgeons
and
Congress of Neurological Surgeons

CHAIRMAN July 2001

M. Ross Bullock, MD, PhD
Division of Neurosurgery Dear Colleague:
Medical College of Virginia
1200 E. Broad Street
PO Box 980631
Richmond, Virginia 23298
Recent changes have taken place in federal regulations governing the
Phone: (804) 828-9165 delivery of trauma and emergency care. One in five neurosurgeons in the
Fax: (804) 828-0034
Email: robulloc@hsc.vcu.edu United States now receives stipends ranging from $500 to $1,500 per
CHAIRMAN-ELECT night for providing emergency room coverage at trauma centers.
Donald W. Marion, MD
Departme nt of Neurosurgery
University of Pittsburgh The purpose of this mailing is to provide neurosurgeons with background
200 Lothrop Street, Suite B-400
Pittsburgh, Pennsylvania 15213-2582 information to facilitate the negotiation of such stipends with their
Phone: (412) 647-0956
Fax: (412) 647-0989 hospitals.
Email: dmarion@neuronet.pitt.edu
SECRETARY-TREASURER
Alex B. Valadka, MD
In this packet, we include the following items:
Department of Neurosurgery
Baylor College of Medicine
6560 Fannin, Suite 944 1. Overview of neurosurgical contracts for trauma coverage.
Houston, Texas 77030
Phone: (713) 798-4696
2. Position statement from the American Association of Neurological
Fax: (713) 798-3739 Surgeons and Congress of Neurological Surgeons concerning
Email: avaladka@bcm.tmc.edu
AANS Liaison
emergency room coverage.
Brian T. Andrews, MD 3. Background information regarding EMTALA.
ABIC Liaison 4. Sample contracts.
Raj K. Narayan, MD
CNS Liaison
5. Abbreviated list of CPT and ICD-9 codes for neurotrauma
Nelson M. Oyesiku, MD, PhD procedures.
Fellowship s/Awards
Michael G. Fehlings, MD, PhD
Guidelines
The Trauma Section hopes this informational packet will make it easier for
Jam Ghajar, MD, PhD all neurosurgeons to provide the best possible care to neurotrauma
Head Injury patients.
Peter B. Letarte, MD
International Outreach
Nelson M. Oyesiku, MD, PhD
Internet/Media M. Ross Bullock, M.D., Ph.D., Chairman
David M. McKalip, MD
Membership
Trauma Section
Jamie S. Ullman, MD
Organ Donation Alex B. Valadka, M.D., Secretary-Treasurer
Jamie S. Ullman, MD
Pediatrics
Trauma Section
P. David Adelson, MD
Prevention/Think First Donald W. Marion, M.D., Chairman-Elect
Michael J. Caron, MD
Reimbursement and Coding
Trauma Section
Donald W. Marion, MD
Resident Liaison John McVicker, M.D., Past Chair
Geoffrey T. Manley, MD, PhD
CSNS Neurotrauma Committee
Spinal Injury
Michael G. Fehlings, MD, PhD
Sports Medicine Katie Orrico, J.D., Director
Julian E. Bailes, Jr., MD
Washington Committee
Washin gton Committee Liaison
Donald W. Marion, MD
Members-at-Large
Robert C. Cantu, MD
John H. McVicker, MD
(Reproduced, with permission, from the Spring 2001 newsletter of the AANS/CNS Section
on Neurotrauma and Critical Care.)

NEUROSURGICAL CONTRACTS WITH TRAUMA HOSPITALS

John McVicker, M.D.

In many communities, neurosurgeons are expected to take call as a condition of

medical staff membership. Emergency Medical Treatment and Active Labor Act
(EMTALA) regulations dictate that specialty availability on a hospital call
schedule must extend to the hospital Emergency Department (ED), obligating
medical staff to trauma call. As hospital systems expand, market, and in many
cases profit from participation in trauma care delivery, the neurosurgeon’s
available time for reliably compensated elective activities diminishes. This
situation is disproportionately worsened by there being comparatively fewer
available neurosurgeons relative to other high-demand trauma specialists, such
as orthopedic surgeons. Even though neurosurgery is a small specialty, 57% of
all high-acuity trauma patients have some neurologic injury, and half of the
150,000 injury-related deaths that occur annually in the United States involve a
serious brain injury that is primarily responsible for the patient’s demise [1].
Obviously, neurosurgical availability is key to the success of a trauma program.
However, many neurosurgeons now opt out of taking ED call because they
simply cannot afford the loss of time and revenue such a service entails [2].

Maintaining enthusiastic support for a trauma program by a medical staff is not

an easy assignment for the average community hospital. Contractually agreed-
upon call stipends are a reasonable way to assure adequate neurosurgical
coverage by an institution that has made such a commitment. Contracts between
trauma hospitals and neurosurgeons can guarantee neurosurgical call
availability, as well as mandate neurosurgical participation in quality assurance,
education, and protocol and program development, including trauma program
outreach. Contracts improve the institution’s ability to meet EMTALA obligations,
help assure the institution meets standards required for trauma center
verification, and improve coordination among trauma specialists. In addition, the
pending Balanced Budget Reform Act of 2000 includes a section (§204) that may
allow hospitals to include on-call stipends in their hospital cost reports, which will
provide the hospitals direct means of obtaining Medicare reimbursement for
these expenses. Such contracts may provide the funds necessary to bring
needed neurosurgical workforce to a community and may be the only way some
neurosurgeons can afford to remain on a medical staff that requires participation
in trauma.

Typical neurotrauma contracts include several sections. Hospital obligations

should be spelled out regarding equipment requirements (CT, MRI, microscope,
etc.), staffing requirements (ED, intensive care unit, operating room, 24-hour
radiology, etc.), and transfer agreements with other hospitals. Transfer
agreements are ideally worked out in the context of a state or regional trauma
system and should include predefined criteria to avoid EMTALA violations.
Unavoidable unavailability of the surgeon and any back-up call requirements, if
necessary, should be addressed. Trauma Program requirements (trauma
coordinator, secretarial support, etc.) are the hospital's responsibility. The
contract should define neurosurgeon or neurosurgical group responsibilities such
as frequency and duration of call and back-up availability, negotiated appropriate
to trauma level, average acuity, trauma volume, and available workforce; no
neurosurgeon should be expected to cover a trauma service beyond the limits of
a safe and reasonable workload. The contract should spell out required
committee involvement, anticipated protocol development and updating, and
expectations for participation in medical and nursing staff education and trauma
outreach programs. Reimbursement type, amount and methodology and whether
the contract is with individuals or groups should be decided. Defining peer review
and quality assurance parameters is of significant importance.

Most of the problems that a hospital may face if it enters into a contract for
neurotrauma coverage and program development are more perceived than real.
For example, the “snowball” effect of various other trauma specialties lining up
for costly stipends has not materialized in hospitals that have instituted this
practice for neurosurgery, with the exception of trauma surgeons or trauma
anesthesiologists who are required to provide coverage in-house. On the other
hand, specifically dangerous to the institution is any implication that a
neurosurgeon who contracts for trauma coverage is compelled to bring elective
work to the hospital. Major regulatory concerns have arisen over these anti-
kickback “payment for referral” issues, and hospital systems have been made to
pay considerable fines and have undergone substantial federal scrutiny for such
schemes. Nevertheless, legal analysis suggests that physicians could expect fair
market compensation for services that go beyond usual medical staff obligations.
When limited workforce and high reliance on neurosurgical trauma services are
factored in, it is apparent that neurotrauma coverage commonly demands more
from the neurosurgeon than general emergency coverage does of the average
medical staff member and is thus worthy of additional compensation at fair
market value [1].

Estimating fair market value then becomes critical in structuring a fair

neurotrauma contract. The best yardstick of this value in a community may be
local or regional data as long as demographics, average Injury Severity Scores,
and the like are comparable. These figures are difficult to come by, and large
regional and demographic variability is likely to exist. National figures will reflect
reimbursement methodology for similar institutions more broadly, but such data
compilations are likewise not widely available. The Council of State
Neurosurgical Societies (CSNS) has recently completed a national Internet
survey on key socioeconomic parameters of emergency ne urosurgery and
neurotrauma. The survey was to address the national spectrum of contractual
and practical agreements between neurosurgeons and the hospitals and systems
in which they practice. Of the 263 respondents, 91% actively participated in
trauma, about half urban and half suburban or rural. Sixty-two percent of
respondents were in private practice, 28% in academics, and 10% were salaried.
Level 1 trauma centers accounted for 40% of the institutions, with Level 2 about
30%, and Level 3 and undesignated about 30%. About one in three respondents
had a formal contract for neurotrauma coverage with their institution.

Compared to limited prior surveys [3,4], contractual arrangements with hospitals

for the provision of neurotrauma care appear to be growing more prevalent.
Nineteen percent of respondents in the CSNS survey were directly reimbursed
for trauma call availability, and over 31% received some form of financial
incentive to participate (see following paragraph). Call stipends were about twice
as frequent in private and salaried practices (21%) as in academic practices
(11%) and tended to be in a lower range (mode $500-1000) in academics and
salaried positions than in private practice (mode $1000-1500). As a general rule,
call coverage was more freque nt, less likely to be reimbursed (or reimbursed at a
lower rate), and more likely to be mandatory at Level 3 and undesignated trauma
centers than at Level 1 or 2 centers. Over 75% of all respondents reported call
coverage to be mandatory at their institution. Half the unreimbursed respondents
reported trauma call to be disruptive to their practices “most of the time,” while
about a third reported the same level of disruption if stipends were in place.
Hence, stipends appear to allow a practice to adjust in part to the additional time
and resources required to participate in trauma call.

Neurosurgeons and their hospitals have developed a variety of creative

arrangements for making trauma coverage both fiscally and physically
responsible. Smaller community hospitals with a limited number of
neurosurgeons have worked out cross-coverage arrangements, periodic locum
tenens, or temporary transfer agreements to shield their neurosurgeons from the
burden of excessive call requirements. Hospitals may bill patients directly and
reimburse a guaranteed percentage of the neurosurgeon’s trauma receivables or
simply provide billing services for the neurosurgeon. Hospitals may supply on-
campus office space to allow for ready neurosurgical availability. Since
neurotrauma coverage is widely perceived as increasing exposure to
medicolegal liability, some institutions have agreed to pay for additional
malpractice coverage and, in some cases, cover the entire amount.
"Neurotrauma Director" positions may be created for neurosurgeons most
involved in program development, along with a negotiated annual consulting fee.

In summary, neurotrauma contracts can be a win-win situation for the

neurosurgeon and the hospital. The hospital can reduce its EMTALA exposure,
improve its performance in the trauma center verification process, and ensure
neurosurgical participation in quality assurance and program development by
supporting the concept of voluntary trauma contracts. For the neurosurgeon,
these contracts help alleviate the double burden of providing mandatory
uncompensated care even as reliably compensated elective practice is
negatively impacted. Everyone negotiates for and knows what their agreed-upon
responsibilities in the provision of trauma care will be, and excessive and
potentially unsafe workload on the neurosurgeon can be avoided. These legal
agreements appear to be increasingly prevalent nationwide. Contractual
relationships between neurotrauma centers and trauma neurosurgeons that
include reimbursement for guaranteed availability will greatly facilitate
neurosurgical participation in trauma care as they become common practice.

References:

1. Harrington TR: Neurosurgical manpower needs--Achieving a balance. Surg

Neurol 47:316-320, 1997.

2. Girotti MJ, Leslie KA, Inman KJ, et al: Attitudes toward trauma care of
surgeons practising in Ontario. Can J Surg 38:22-26, 1995.

3. Hoyt TE: Neurosurgery E.R. Survey. California Association of Neurological

Surgeons Newsletter, Summer 24:2-3, 1997.

4. McVicker J: Joint Council of State Neurosurgical Societies Interim Report. Ad

Hoc Committee on Neurotrauma. Chicago: AANS/CNS, 1997.
 POSITION STATEMENT

of the

American Association of Neurological Surgeons

and
Congress of Neurological Surgeons

IMPROVING ACCESS TO EMERGENCY NEUROSURGICAL SERVICES

BACKGROUND

The Emergency Medical Services (EMS) system is in the midst of a growing crisis because of a
recognized shortage of on-call specialists. This problem extends to the provision of emergency
neurosurgical care. Since neurosurgeons are a vital component of the EMS system, their active
participation is essential. Reimbursing neurosurgeons for serving on-call to hospital emergency
departments is therefore appropriate.

JUSTIFICATION

1. Within their capabilities, hospitals have a legal obligation under the Emergency Medical
Treatment and Labor Act (EMTALA) to provide screening and stabilization services to patients
who come to emergency departments. As part of this obligation, hospitals are required to
maintain a list of physicians who are on-call to treat patients in the emergency room and to
ensure that on-call physicians respond when called.

2. Neurosurgeons have a variety of financial and contractual problems with managed care plans.
In many instances, these contracts have no on-call arrangement, or require on-call availability
without reimbursement, or have reimbursement rates that are extremely low. Because of
these and other economic pressures, neurosurgeons are finding it increasingly difficult to
subsidize emergency medical care through internal "cost-shifting," thus limiting their ability to
subsidize their own on-call activities.

3. Neurosurgeons are faced with increased risks and liability when providing emergency care.
Because of the seriousness of cases in the emergency medical setting and because of the lack
of a pre-existing physician/patient relationship, neurosurgeons have a greater potential to be
part of a medical malpractice action. In addition, neurosurgeons who provide on-call services
must also comply with the mandates of EMTALA, subjecting them to potential fines of $50,000
for any violations of this complex law and regulations.

POSITION STATEMENT

To facilitate the availability of neurosurgeons for on-call services to hospital emergency

departments, hospitals may provide neurosurgeons with reasonable compensation for serving on
the on-call panel. This compensation should supplement any reimbursement the neurosurgeon
receives for services rendered while serving on-call.

Approved by Board and Executive Committee

April 20, 2001
Neurosurgical Issues Regarding ED Call and EMTALA
Date: 3/26/01

To: Washington Committee

From: John A. Kusske, M.D.

Re: Neurosurgery Emergency Department Coverage

______________________________________________________________________________

This report will summarize some of the issues that might be considered when the problem of
emergency room coverage provided by neurosurgeons is discussed. A part of this discussion must
relate to the emergency transfer laws as they apply specifically to the medical staff and physicians
who serve on-call to the emergency department. Further, the lack of adequate neurosurgery coverage
or back-up coverage in some hospital emergency departments (EDs) is also integrated into the theme
of this statement, as well as payment of stipends for emergency neurosurgical care.

Medical Staff Obligations

1. What are the obligations of medical staffs under the emergency transfer laws?

In most states medical staffs have a duty to consult with their hospitals in developing policies and
transfer protocols. Medical staffs should work with their hospitals if they do not have these policies
and transfer protocols. Also, in some states the protocols are to be submitted to the state agency
regulating the hospitals.

With respect to federal law, the Interpretive Guidelines set forth in Appendix V to the HCFA State
Operations Manual (HSOM) provide that:1

The medical staff bylaws or policies and procedures must define the responsibility of on-call
physicians to respond, examine, and treat patients with emergency medical conditions.
Interpretive Guidelines at Tag Number A404.

In addition, the hospital (through the medical staff) must have policies and procedures to be followed
when a particular specialty is not available or the on-call physician cannot respond because of
situations beyond his or her control. Id2.

The AMA recommends that the medical staff should have a primary role in the development of
educational materials and review sessions for physicians and hospital personnel to assure that they
understand the on-call procedures and emergency transfer laws.
__________________
1
These guidelines do not have the force of law but are important because when HCFA surveyors investigate
alleged violations of law, they use the Guidelines to decide whether an actual violation occurred.
2
While the Interpretive Guidelines technically impose this requirement upon the hospital, given the fact that the
self-governing medical staff is responsible for assuring patient care, active medical staff involvement si
warranted here.
 3/26/01 Neurosurgical Issues Regarding ED Call and EMTALA: Neurosurgery ED Coverage 2

Physician Obligations to Serve On-Call

2. What are medical staff members’ obligations with respect to on-call coverage?

Neither federal nor any state law I know of affirmatively requires an individual physician to serve “on-
call”. Rather, the responsibility to provide specialty medical coverage rests with the facility that offers
emergency services. However, it is obviously the physicians on the medical staff who must provide
the professional services. Thus, if the hospital and medical staff agree to maintain the emergency
department, medical staff members, either voluntarily or through some other mechanism, will have to
serve on-call.

Assuming that emergency services will continue to be provided, medical staffs and governing boards
have considerable latitude to come up with creative and cooperative solutions to emergency
coverage. Different medical staffs, different communities, even different departments within the same
medical staff may address the issue in unique ways to deal with the unique characteristics of their
situation. These might include, but are not limited to: (a) voluntary on-call coverage, (b) mandatory on-
call coverage as a condition of medical staff membership, (c) contracting for on-call services (e.g.,
payment of stipends), (d) insurance coverage for on-call physicians, (e) compensation for some
portion of the uncompensated care rendered by on-call physicians, and (f) “call sharing” arrangements
with other hospitals. There is no need that the policy be uniform across all departments if such
uniformity would result in unfair burdens to some specialists. Indeed, exceptions may be made even
within a department or within the staff as a whole where that exception is reasonable.3

3. What obligations does a physician have when he/she agrees to serve on-call?

Once a physician accepts on-call responsibilities, the physician must comply with the emergency
transfer laws and may be liable for failure to do so. The laws prohibit an on-call physician from
refusing to respond for any nonmedical reason.

Federal law is not as specific as some state laws regarding on-call responsibilities. However, federal
law does require the hospital to maintain a list of physicians who are on call to provide stabilizing
treatment to patients after the initial screening examination. (42 U.S.C. §1395cc(a)(I)(I).)4 The
Interpretive Guidelines make it clear, however, that physicians, including specialists and
subspecialists, are not required to be on-call at all times. Tag Number A4040. Nonetheless, the
Guidelines continue:

The hospital must have policies and procedures to be followed when a particular specialty is
not available or the on-call physician cannot respond because of situations beyond his or her
control. ld.

_________________________________________
3
Emergency Transfer Laws: Medical Staff and On-Call Requirements. Document #1216 CMA Legal Counsel,
Feb. 2001.
4
The Interpretive Guidelines provide that the purpose of this on-call list is to ensure that the emergency
department is prospectively aware of which physicians are available to provide treatment necessary to stabilize
individuals with emergency medical conditions. Tag Number A404.
 3/26/01 Neurosurgical Issues Regarding ED Call and EMTALA: Neurosurgery ED Coverage 3

Again, given the medical staff’s role in patient care, the medical staff should approve and be involved
in the development of these policies.

HCFA’s Interpretive Guidelines provide additional information concerning on-call physicians’ rights
and responsibilities. For example, according to HCFA:

• Physicians are not required to be on-call in their specialty or subspecialty for emergencies when
they are visiting their own patients in a hospital.

• If a physician is on-call to provide emergency services or to consult with an emergency room

physician in an area of his or her expertise, that physician would be considered to be available at
the hospital.

• Where a physician is on-call in an office, it is not acceptable to refer emergency cases to the
physician’s office for examination or treatment. The physician must come to the hospital to
examine the patient unless the physician is in a hospital-owned facility on contiguous land or on
the hospital campus.

• If a physician demonstrates a pattern of not arriving at the hospital while on call, but directs the
patient to be transferred to another hospital where that physician can treat the patient, this may be
a violation.

Tag Number A404

4. What can physicians do to limit their risk of liability?

It is essential that physicians who serve on-call take steps to protect themselves from the risk of
liability. For example, it may be advisable to institute some sort of date- and time- specific roster of on-
call coverage, such that there is no question as to which staff members are on-call and when.
Because federal law requires a hospital to maintain a list of physicians who are on-call and to report
physicians who do not respond when called, informal or ad hoc arrangements are no longer viable.
Hospitals and medical staffs that are unable to provide this coverage may be forced to establish
arrangements with other hospital(s) to share call, seek a reduction in scope of services, or eliminate
their EDs.

Mandatory On-Call Policies

5. Can a hospital medical staff with no particular on-call provisions in its bylaws force
a physician to serve on a mandatory call list?

Under most medical staff bylaws, a medical staff member agrees to be bound not only by the medical
staff bylaws, rules and regulations, but also by all duly adopted policies of the medical staff.
Therefore, if the medical staff adopts a policy calling for mandatory on-call service, a medical staff
member will be bound by the policy. Policies that concern matters of controversy should be adopted
by the medical staff acting as a whole, rather than solely by a committee, such as the Medical
Executive Committee. If a medical staff committee adopts and attempts to enforce a mandatory on-
call policy on its own, under most bylaws, any medical staff member (acting with others) may call for a
special medical staff meeting, at which any policy may be revoked and/or a new policy may be
considered for adoption by the entire medical staff.
 3/26/01 Neurosurgical Issues Regarding ED Call and EMTALA: Neurosurgery ED Coverage 4

6. Can a hospital medical staff include in its bylaws provisions that require a physician
to serve on a mandatory call list?

Yes. If the bylaws are approved through the prescribed channels (generally through a vote of the
medical staff membership and subject to governing body approval), then all medical staff members
will be bound by the terms of the bylaws.

Other Coverage Options

7. Are there alternatives to a mandatory on-call policy?

Yes. Rather than attempt to institute unilaterally a mandatory on-call policy, the hospital should work
with the medical staff toward a mutually acceptable solution. Careful consideration by both the
medical staff and hospital should be given to all possible options, some of which were listed earlier in
this document.

8. Recommendations Regarding Potential Lack of ED Backup

Recommendation 1—Hospital and Medical Staff Policies and Procedures. Hospitals and their medical
staffs should have policies and procedures to assure that they fulfill their shared ethical responsibility
for the provision of emergency care. These policies and procedures should be clearly delineated as
part of the medical staff bylaws, or rules and regulations, and should contain appropriate mechanisms
to assure performance. Policies should also assure that all participating physicians understand the
medical screening, stabilization and transfer requirements of EMTALA, in order to improve
compliance and minimize medical-legal risks. Medical staffs should be required to maintain a
grievance system, e.g., the medical staff peer review or corrective action process, for resolution of
disputes between EDs and on-call specialists over on-call specialty coverage. Medical staffs should
adopt and enforce policies and procedures which delineate the circumstances under which a failure to
respond or to come to the ED is justified, and alternatively, when and whether penalties are justified.

Recommendation 2—Contracting for On-Call Services. Hospitals and interested members of their
medical staffs should be encouraged to develop, in compliance with applicable law, emergency
service IPAs and consolidated billing and coding arrangements in communities where such
arrangements may create economies of scale that are beneficial for the provision of ED on-call
coverage. Consideration should be given to supporting legislation that would facilitate these
arrangements.

Recommendation 3—Payment of Stipends and Other Incentives. Hospitals and their medical staffs
should work together to develop incentives and compensation mechanisms that adequately reward
physicians, both for the provision of emergency care and for their service in providing standby
coverage for the community. Hospitals should pay stipends to on-call physicians who are required to
provide care for a disproportionate number of Medicaid and uninsured patients. In addition, such
stipends should be considered for certain specialties that are disproportionately burdened due to a
scarcity of the specialty in the geographic area or due to excessive caseloads or intensity of services
required. The medical staff should be actively involved in all decisions regarding stipends.
 3/26/01 Neurosurgical Issues Regarding ED Call and EMTALA: Neurosurgery ED Coverage 5

Recommendation 4—Payment Mandates for and Responsibility by Managed Care Plans and
Insurers. All HMOs, IPAs, PPOs, and indemnity insurers should be required to pay directly for
provision of emergency care, in accordance with the contracted rate with respect to emergency
services provided by contracted physicians, or on a uniform RBRVS-based fee schedule for services
provided by noncontracted physicians. A similar methodology should be used for the reimbursement
of facility services. Each managed care and insurance entity should be required to set aside an
emergency services reserve fund for these payment purposes. Funds could be maintained through
withholds of total insurance premiums paid to plans by employers.

All interested parties should support ongoing legislative efforts to require payors to pay treble
damages for unpaid or inappropriately paid claims, plus a 30% interest penalty for late payment.
Moreover, physicians who provide emergency services should be educated as to their legal right to
compensation for emergency care and should be empowered to obtain redress through civil and
regulatory means.
 SECTION ON NEUROTRAUMA
AND CRITICAL CARE
HEAD INJURY SPINAL CORD INJURY SPORTS MEDICINE CRITICAL CARE PREVENTION

A Section of the
American Association of Neurological Surgeons
and
Congress of Neurological Surgeons

CHAIRMAN
M. Ross Bullock, MD, PhD
Division of Neurosurgery
Medical College of Virginia
Enclosed are two sample contracts. Comparing their similarities
1200 E. Broad Street
PO Box 980631
and differences is very interesting. As you can see, each contract
Richmond, Virginia 23298
Phone: (804) 828-9165
has been tailored to address the specific concerns of the
Fax: (804) 828-0034 neurosurgeons at that particular facility. Also note that separate
Email: robulloc@hsc.vcu.edu
CHAIRMAN-ELECT
contracts exist: one for the group to provide neurotrauma
Donald W. Marion, MD
Departme nt of Neurosurgery
services, and another for an individual neurosurgeon to be the
University of Pittsburgh
200 Lothrop Street, Suite B-400
“Neurotrauma Director”.
Pittsburgh, Pennsylvania 15213-2582
Phone: (412) 647-0956
Fax:
Email:
(412) 647-0989
dmarion@neuronet.pitt.edu
Please keep in mind that a contract which demands more of a
SECRETARY-TREASURER
neurosurgeon’s time and effort should stipulate more
Alex B. Valadka, MD
Department of Neurosurgery
reimbursement than a contract that requires a smaller
Baylor College of Medicine
6560 Fannin, Suite 944
commitment.
Houston, Texas 77030
Phone: (713) 798-4696
Fax: (713) 798-3739 These examples are provided only as educational and
Email: avaladka@bcm.tmc.edu
AANS Liaison
informational items. The AANS/CNS Section on Neurotrauma
Brian T. Andrews, MD
and Critical Care recommends that any neurosurgeons who are
ABIC Liaison
Raj K. Narayan, MD considering entering into similar agreements with their hospitals
CNS Liaison
Nelson M. Oyesiku, MD, PhD
seek professional legal advice.
Fellowship s/Awards
Michael G. Fehlings, MD, PhD
Guidelines
Jam Ghajar, MD, PhD
Head Injury
Peter B. Letarte, MD
International Outreach
Nelson M. Oyesiku, MD, PhD
Internet/Media
David M. McKalip, MD
Membership
Jamie S. Ullman, MD
Organ Donation
Jamie S. Ullman, MD
Pediatrics
P. David Adelson, MD
Prevention/Think First
Michael J. Caron, MD
Reimbursement and Coding
Donald W. Marion, MD
Resident Liaison
Geoffrey T. Manley, MD, PhD
Spinal Injury
Michael G. Fehlings, MD, PhD
Sports Medicine
Julian E. Bailes, Jr., MD
Washin gton Committee Liaison
Donald W. Marion, MD
Members-at-Large
Robert C. Cantu, MD
John H. McVicker, MD
SAMPLE CONTRACT #1
 NEUROSURGERY COVERAGE PROFESSIONAL SERVICES AGREEMENT
PART A
EXCLUSIVE NEUROSURGERY SERVICE COVERAGEB RESPONSIBILITIES AND DUTIES

This agreement is attached to, made a part of and executed simultaneously with that certain
Professional Services Agreement between the undersigned, dated................

EXCLUSIVE 24-hour neurosurgery coverage for the Facility Emergency Department and
Trauma Program shall be provided by Contractor on a 24-hour-per- day, 7-day-per-week
basis, in accordance with such schedules as may be determined by the Neurosurgery
Program Medical Director or his designee from time to time. This 24-hour neurosurgery
coverage shall be for neurosurgery services required by Facility, its Emergency Department,
Trauma Program (appropriate for Facility=s Trauma designation) and inpatient and outpatient
patient care needs.

Contractor agrees to the following criteria:

1. In conjunction with the Facility=s Medical Staff Office and Administration, Contractor
shall have exclusive and sole duty to establish and manage a monthly neurosurgery call
schedule for the Facility=s Emergency Department and Trauma Program (appropriate
to Facility=s Trauma designation). Contractor, in addition to a reliable call schedule,
shall have a formally arranged contingency plan in the event the capability of the
neurosurgeon, Facility or system to care for neurotrauma is overwhelmed.

2. 24-hour Neurosurgery Coverage- Contractor will guarantee 100% 24-hour

neurosurgery coverage of the Facility=s Emergency Department and Trauma Program
appropriate to Facility=s Trauma designation and assume any call coverage should
scheduled physicians fail to meet their obligations. Contractor=s failure to provide
100% neurosurgery coverage to the Facility=s Emergency Department and Trauma
Program (appropriate to Facility=s Trauma designation) will be considered a material
breach of this agreement and at Facility=s sole discretion may result in default of this
agreement.

3. One-Institution Requirement- Contractor agrees that physicians on-call may cover

only one (1) institution and, at a minimum, must be of commensurate experience and
training as those on staff.

4. Neurosurgery Qualifications- Contractor shall provide physicians Board-certified or

eligible in the American Board of Neurological Surgery or other equivalent board as
determined by the Facility Medical Staff credentialling process.

a. Education- Contractor shall provide neurosurgeons that have an interest in and a

commitment to emergency medicine and trauma care.

1
5. Clinical Care Parameters- Contractor agrees that neurosurgeons taking neurotrauma
and neurosurgical call shall recognize and adhere to the protocols of FACILITY and
the standards of the community. Further, neurosurgeons will participate as
appropriate in the organization of trauma protocols, trauma teams, and trauma rounds.

6. Medical Staff Policies and Procedures- Contractor agrees to meet all appropriate
Medical Staff Policies and Procedures, including timely response to the Emergency
Department as outlined in the Medical Staff Emergency Department Call Lists, Policies
and Procedures.

7. Regulatory Requirements and American College of Surgeons Committee on

Trauma (ACS COT) Guidelines- Contractor agrees to meet all appropriate State
Trauma Regulations and American College of Surgeons Committee on Trauma
Guidelines appropriate to neurotrauma patients, including timely response to the
Facility. Contractor agrees to meet requirements outlined in the ACS COT=s
Resources for Optimal Care of the Injured Patient.

8. Follow-up Visits- Contractor agrees to provide the requisite number of follow-up visits
required post-hospitalization to Emergency Department and Trauma program patients.

Call Availability
Contractor shall require neurosurgeons meet the On-Call and Promptly Available on Short
Notice requirements of the State and ACS COT. A neurosurgeon must be promptly and
continuously available to provide neurotrauma care for severe head and spinal cord injuries,
as well as less severe head and spinal cord injuries. See Neurosurgery Timeliness
Response Requirements (PART C).

Call Schedule Notification Requirements

$ Month=s Call Schedule Advance Notice- Contractor shall provide a Monthly Call
schedule to the Facility=s Administration, Medical Staff Office, Emergency
Department, and Trauma Service Coordinator prior to the beginning of each month.

$ Revisions & Changes- Contractor shall contact the Medical Staff Office and
Emergency Department with any revisions or changes during the month as required by
the facility=s Medical Staff Rules & Regulations and Policies and Procedures.

$ Final Revised Call Schedule- Contractor shall provide at the end of each month a
revised copy of the Call Schedule including all revisions and changes made during the
month for Facility=s records for regulatory compliance.

2
Neurotrauma Patient Protocol Development
1. Contractor shall advise and consult Facility in developing appropriate protocols to
assist in the care of the neurotrauma patient throughout the continuum of care.
2. Contractor shall actively set and monitor the triage criteria for head and spinal cord
injury.

Trauma Program Development

1. Contractor shall reasonably advise and consult in developing and enhancing
............. image as a Trauma Designated Facility with a Neurotrauma program.
2. Contractor shall reasonably advise and consult in establishing an integrated
credible Neurotrauma Program with Facility Medical Staff in Metro.......
3. Contractor shall reasonably advise and consult Facility Administration and Facility
Trauma Service in developing its trauma center status and image to its full potential.
4. Contractor shall reasonably advise and consult Facility Administration and Facility
Trauma Service in developing a comprehensive and Integrated Trauma Service that
serves the needs of the community.
5. Contractor shall oversee the management of neurotrauma care at ..... This includes
meeting with the appropriate Medical Directors, Nursing Directors and other Directors
as necessary.
6. Marketing Commitment- Work with staff to conduct a reasonable amount of trauma
patient outreach and marketing.
7. Contractor shall reasonably advise and consult Facility Administration and Facility
Trauma Service in developing and participating in an effective and collaborative injury
prevention program.

Verification/Consultation Program Involvement

1. Contractor shall assist Facility in any verification/consultation process to evaluate and
improve the Trauma Care Program and its designation.
2. Contractor shall be involved in the preparation for and the actual on-site visit of
consultants to review Facility=s capability in trauma and the care of patients.
3. Contractor shall be involved in any COT consultation, including but not limited to, pre-
review meetings and on-site review.

Public Education and Professional Education

1. Public Education- Contractor, as reasonably requested, shall assist Facitlity in
educating the public about injury as a significant disease and public health problem.
2. Professional Education/Inservices- Contractor shall, as reasonably requested by
Facility, participate and assist in neurotrauma educational in-service training activities
associated with Facility=s Medical Staff, nursing staff and emergency medical services
staff.

Quality Improvement- Contractor shall participate in quality improvement activities and other
neurosurgery service activities as appropriate.

3
Committee Participation- Contractor and representatives shall, as reasonably requested by
Facility Administration or designee, participate in various Facility committees. This shall
include at a minimum the Facility Trauma Multidisciplinary Committee and any appropriate
Peer Review Committee.

Additional Duties
1. Act as a liaison between Medical Staff, nursing staff, and Facility Administration in
matters regarding the Neurosurgery Section.
2. Ensure that any contract, corporation or association internal policies or disgruntlement,
etc., within the Contractor group shall not interfere with Contractors= performance of its
obligations under this Agreement.
3. Do that which is reasonable to assist in creating a positive reputation and
relationship between the Facility and the community with a sensitivity to
patient satisfaction and public relations of Contractor services.
4. Contractor shall cooperate with other Contractors and with physicians from all other
specialties, including anesthesia, trauma surgery, the Emergency Department,
contracting physicians, as well as Facility nursing and ancillary staff to provide a
cohesive and coordinated neurosurgery and trauma team to maintain the Level II or
Level III designation or such other designations as determined by Facility.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:____________________________________
Chief Executive Officer, as VP of Facility

By:_____________________________________
Facility Ethics & Compliance Officer

4
 PART B
FACILITY OBLIGATIONS TO NEUROTRAUMA AND NEUROSURGERY CALL COVERAGE

Facility is obligated to provide the following items to assist Contractor in meeting obligations
to care for neurotrauma and neurosurgical patients in the Facility.

Facility commits to meeting or exceeding State regulatory and ACS COT requirements
appropriate for the Facility=s Trauma designation. Further, Facility commits to attaining the
optimal patient outcome and the timely availability of healthcare professionals who are
dedicated to providing medical care to the injured patient. Specifically, Facility commits to the
following items:

Radiology/Diagnostic Imaging
CT Availability- Facility is obligated to make available 24-hour in-house CT personnel.
MRI Availability- Facility is obligated to provide 24-hour On-Call availability of MRI
personnel.
Interventional Radiology Availability- Facility is obligated to provide 24-hour On-
Call availability of interventional radiology personnel.
Radiologist Availability- Facility is obligated at a minimum to have 24-hour On-Call
availability.

Operating Room
OR Trauma Team Availability- Facility is obligated to make available 24-hour in- house
OR Surgical Team personnel. This team shall consist of a minimum of one (1) RN, one
(1) scrub tech, one (1) Nursing Assistant. Facility is obligated to provide for an
additional On-Call OR Surgical Team. Facility shall also make available Evoked
Potential technicians.

Neurosurgery & Trauma Surgery OR Clinical Coordinator- Facility is obligated to

provide one (1) RN designated as the Neurosurgery & Trauma Surgery OR Clinical
Coordinator. Such individual shall be selected with the input of Contractor and
Facility=s trauma surgeons, administration and administration=s designees.

Equipment- Facility is obligated to provide such equipment that may be reasonably

expected to be available at a community-based neurosurgical program. Contractor
shall assist Facility in assessing its present situation and recommending
appropriate additions. Such equipment shall include but is not limited to:
Craniotomy sets and appropriate drills
Microscopes based upon utilization
Appropriate surgical tables based upon utilization

5
Additional Personnel
Neurosurgery Clinical Educator- Facility is obligated to provide one (1) RN
designated as the Neurosurgery Clinical Specialist in addition to its present Clinical
Educator complement. Such individual shall be selected with the input of Contractor
and Facility=s trauma surgeons, administration and administration designees. This
Neurosurgery Clinical Specialist works to promote the optimal care for the neurotrauma
and neurosurgical patient through the entire continuum of care including the clinical
program, administrative functions and professional and public education. This
Clinical educator shall also assist in acting as a liaison between the Contractor
and the Facility where appropriate.

Additional Equipment
Intracranial Pressure Monitors- Facility is obligated to provide a minimum of three ICP
monitors and more as appropriate.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:___________________________________
Chief Executive Officer, as VP of Facility

By:___________________________________
Facility Ethics & Compliance Officer

6
 PART C
NEUROSURGERY TIMELINESS GUIDELINES

On-Call Response
Contractor shall be obligated, but not limited, to meet the following guidelines as a definition of
Atimely response@:

Contractor and its subcontractors are required to meet the timeliness requirements of
the Facility Medical Staff Rules & Regulations and Policies and Procedures, the State
Trauma Regulations and the American College of Surgeons Committee on Trauma
(ACS COT).

In providing call for 24-hour Neurosurgery Coverage, Contractor must respond within
10 minutes to all calls or pages concerning neurosurgery patients and be present
within a mutually acceptable time frame that shall be decided by the Trauma Surgeon
(or the Emergency Department physician) and by the covering neurosurgeon.

Additional appropriate time frames for presentment may be determined by Facility

Medical Staff Rules & Regulations and Policies and Procedures, State Trauma
Regulations or ACS COT or as mutually agreed upon by Facility and Contractor.

The On-Call Neurosurgeon shall actively participate in the ongoing resuscitation,

monitoring and treatment of the neurotrauma patient.

Additional guidelines may be amended to these requirements as changes are implemented to

the Medical Staff Rules & Regulations and Policies and Procedures, the State Trauma
Regulations, and the ACS COT requirements.

Operative Procedure Timeliness- The time from ED arrival to operative procedure

shall be determined by Trauma Service Protocols.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:____________________________________
Chief Executive Officer, as VP of Facility

By:_____________________________________
Facility Ethics & Compliance Officer

7
 PART D
NEUROSURGERY PROGRAM DEVELOPMENT

Program Goal- Develop a well established Neurosurgery Program as a business unit to meet
the needs of the Facility and the community it serves in a cost-effective manner. Contractor
shall participate in implementing and developing a community-based neurosurgery program.
Functions shall include participating in, but are not limited to:
$ directing and overseeing the delivery of patient care services to the Facility=s
neurotrauma and neurosurgical patient population.
$ establishing policies and procedures.
$ reviewing process issues.
$ developing, with Facility Quality Management Department and Medical Staff
committees, innovative care management programs for the neurotrauma and
neurosurgical patient population.
$ developing a cost-effective program that is in line with the Facility=s overall objectives
and goals.
$ developing and enhancing Facility=s image as a Facility with a Neurosurgery program.
$ reviewing and analyzing neurosurgery data for program evaluation and utilization.

Clinical Leadership
1. Contractor shall provide clinical leadership to the Facility=s Neurosurgery Program and
work with Facility medical staff, Administration and management team to meet the
needs of its community and organization goals and objectives.

Community-based Neurosurgery Program

1. Develop a group practice organization that will support long-term participation by well
qualified neurosurgeons and establish an integrated and credible Neurosurgery
Program with the Facility Medical Staff, ..... Health System and metro-healthcare
community.
2. Develop a core group of neurosurgeons who provide care in a collaborative manner at
Facility and in the community.
3. Scope of Program- Enhance the breadth and scope of patient care provided to meet
the needs of both the Neurosurgery Program and the Trauma Center and support an
appropriate number of neurosurgeons in the community of......
4. On-Site Availability- Contractor shall make available on-site in a practice setting in
(city) two (2) neurosurgery physicians every business day during normal business
hours. Business hours shall be reasonably defined by Contractor. (On-site shall be
defined as any of Facility=s campuses or property contiguous to Facility=s campuses.)
$ Contractor shall specifically make available to The Medical Center of....
development and implementation of a Neurosurgery Program for year ONE of
the contract.

8
Marketing Commitment
1. Contractor shall work with Facility Administration and Trauma Program to market
Neurosurgery Program to Medical Staff and community.

Neurosurgical Patient Care Protocol Development and Clinical Involvement

1. Contractor shall advise and consult with Facility in developing appropriate protocols to
assist in the care of the neurosurgical patient through the continuum of care.
2. Reasonably advise and consult in developing protocols, treatment plans and tools to
assess patients and patient care goals and to identify outcomes.

Personnel and Resources

1. Contractor shall assist Facility in identifying personnel and resources as needed to
provide for care of the neurosurgical patient through the continuum of care.

Professional Education
1 Professional Education/Inservices--Contractor shall, as reasonably requested by
Facility, participate and assist in neurosurgery educational in-service training activities
associated with Facility=s Medical Staff, nursing staff and emergency medical services
staff.

Committee Participation
1. Contractor and representatives shall participate in various Facility committees as
reasonably requested by Facility Administration or designee. This shall include at a
minimum the Facility Peer Review Committee and the Medical Records Review
Committee as requested by Facility Administration.

Additional Responsibilities
1. Situational Assessment- Participates, advises and consults in the development
of a plan of care for the neurosurgical patient through an interdisciplinary team
process in conjunction with the patient and family in internal and external settings.
$ On a concurrent basis, assess the appropriateness of the level of
neurosurgical care; diagnostic testing and clinical procedures; quality and
clinical risk issues and documentation of medical record completeness.
2. Reasonably advise and consult in systematically implementing and evaluating
opportunities for program improvement, including clinical pathways, protocols, and
other mechanisms to improve patient outcomes.
3. Reasonably advise and consult in assessing, identifying and communicating cost-
effective alternative delivery methods based on the neurotrauma and neurosurgical
patient population and individual patient=s clinical and functional status.
4. Reasonably advise and consult in designing and reviewing quality monitoring
activities in association with the Emergency Department, Trauma Program,
Perioperative Services and the Quality Management Department.

9
5. Reasonably advise and consult in identifying and addressing suspected problems
of over- or underutilization or inappropriate scheduling of services and bringing issues
to the attention of the appropriate Facility designee such as Director of Quality
Management, Director of Perioperative Services, or Trauma Medical Director.
6. Advise and consult with Facility Administration regarding staffing needs, assignment o f
personnel, and scheduling of personnel in the appropriate departments.
7. Reasonably advise and consult in the budgeting process and control of resources
of the appropriate departments in accordance with Facility policy.
8. Act as a liaison between Medical Staff, nursing staff, and Facility Administration in
matters regarding the Neurosurgery Section.
9. Reasonably ensure a positive reputation and relationship between the Facility
and the community with a sensitivity to patient satisfaction and public relations
of Contractor services.
10. Contractor shall, as reasonably requested by Facility, participate in Facility-
designated community programs to promote patient care at the Facility.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:____________________________________
Chief Executive Officer, as VP of Facility

By:_____________________________________
Facility Ethics & Compliance Officer

10
 PART E
NEUROSURGICAL COVERAGE

$...... a day not to exceed $....... a year for 24-hour neurosurgical coverage as outlined in
PART A.

Additionally, in Year ONE Facility shall pay contractor $.... a month not to exceed $.... a year
for the maintenance of the Neurosurgical Call schedule.

Initial Fee of $..... shall be paid in the first month of the agreement for the initial
development of the Neurosurgical Call schedule.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:____________________________________
Chief Executive Officer, as VP of Facility

By:_____________________________________
Facility Ethics & Compliance Officer

11
 PART F
REIMBURSEMENT FOR NEUROTRAUMA OR TRAUMA

Trauma-Related Continuing Medical Education: The Employer will pay and/or reimburse
the Contractor up to $..... per year per Physician expended in connection with the physician
attending medical conventions and/or reasonable continuing medical education seminars,
including travel, lodging and meals.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:____________________________________
Chief Executive Officer, as VP of Facility

By:_____________________________________
Facility Ethics & Compliance Officer

12
 PROFESSIONAL SERVICES AGREEMENT ADDENDUM
ROLE DESCRIPTIONB NEUROSURGERY MEDICAL DIRECTOR

This addendum is attached to, made a part of and executed simultaneously with that certain
Professional Services Agreement between the undersigned, dated the ...... day of ...., .....

NOW, THEREFORE, in consideration of the agreement herein contained and for the good and
valuable consideration, the parties hereto agree as follows:

Role Summary

The Role of the Medical Director is to assist in designing, implementing, and enhancing
systems that support the development of a complete, comprehensive community- based
neurosurgery program.

The Medical Center of ........ Neurosurgery Medical Director is responsible for the medical
management of the Neurosurgery program at ...... He/she must support the philosophy of the
system by maintaining the dignity of the individual, enhancing the quality of human life, and
providing our patients with the best medical care possible.

.... Neurosurgery Medical Director represents the Neurosurgery Section at departmental

meetings and reports to the Surgery Committees on programmatic issues. ..... Neurosurgery
Medical Director works with .... Trauma Medical Director and closely with the Medical
Directors of Emergency Medical Services.

Participation in the clinical activities of the Neurosurgery Services is integral to the successful
completion of the responsibilities listed below.

Responsibilities

Clinical Operations

1. Oversees daily operations of Neurosurgery-related activity at ..., including the OR, ICU,
ED, EMS, and Radiology.

2. Serves as facility Neurosurgery Medical Director at ....

3. Takes Neurosurgery call in scheduled rotation.

4. Provides relief Neurosurgery coverage for Neurosurgeons during weekday hours as

mutually established with Administration and the Neurosurgery Surgeons.

5. Organizes teams of physicians from appropriate medical and surgical specialties at

..... to provide the necessary clinical services for Neurosurgery patients.

13
6. Participates in Neurosurgery-related clinical rounds within the System.

7. Assists in the coordination with appropriate heads of nursing and ancillary departments
in defining the necessary nursing and support services required for the Neurosurgery
program, and works with system administration and medical/nursing staff to implement
these services.

8. Works with the department of Emergency Medical Services and Trauma to ensure
appropriate communication of Neurosurgery education, policy, and protocol to all
hospital departments and EMS agencies.

Service Operations

1. Evaluates participation, contributions and performance of attending Neurosurgeons.

2. Assigns responsibilities to other Neurosurgeons as appropriate.

3. Appoints appropriate designees and collaborates in the completion of Neurosurgery

rotation and call schedules.

4. Recommends policies governing the operation of the Neurosurgery Service.

5. Directs and collaborates in the preparation of patient cases for Neurosurgery morbidity
and mortality conferences.

6. Provides feedback to outreach hospitals/physicians as appropriate.

Maintenance of Trauma Center Status

1. Assists in directing ...... Neurosurgery administrative staff in organizing, directing, and

maintaining the Neurosurgery program to meet criteria for Trauma designations as
outlined by the American College of Surgeons and the State Trauma Committee. The
services must also meet requirements of the Joint Commission on Accreditation of
Healthcare Organizations.

2. Assists in the preparation of the application for the ...... Trauma Center verification
process through ....... or whatever means the state has in place at time of reverification
of Trauma Center Designation.

3. Participates in the design and implementation of future programs relating to

Neurosurgery activities including but not limited to:
a. Outreach programs
b. Upgrading Trauma Center designations
c. Networking with affiliated hospitals

14
Committee Responsibilities

1. Represents Neurosurgery at the Trauma Committee, which has the responsibility for
patient care protocols, quality assurance, morbidity and mortality, peer review, and
evaluation of performance of the Neurosurgeons= compliance with the policies of the
Neurosurgery Section.

2. Serves on the following committees and attends the following meetings as appropriate:
a. Trauma and/or Neurosurgery Service Conferences
b. Trauma and/or Neurosurgeon=s Education Conference
c. Trauma Quality Assurance Committees
d. Morbidity and Mortality Conferences
e. Critical Care Committees
f. Trauma and/or Neurosurgery Systems Meetings
g. Surgery Committees
h. Medical Executive Committee as appropriate
i. Department of Surgery Meetings

Hospital Operations

1. Assists and participates with the Trauma Clinical Coordinator and Neurosurgery
Clinical Specialist and other hospital personnel in conducting the necessary quality
assurance activities to ensure the proper functioning of the ..... program. Participates in
initial QA review as requested by the Trauma Clinical Coordinator and Neurosurgery
Clinical Specialist.

2. Assists the Trauma Clinical Coordinator and Neurosurgery Clinical Specialist in

complying with and maintaining Trauma registry reporting requirements.

3. Provides input to Administration for the operating and capital budget needs of the
Neurosurgery section.

4. Provides input to Administration in the selection of Neurosurgery OR staff members.

5. Provides input to Administration for the annual performance appraisal for Neurosurgery
OR staff members.

6. Meets with the Trauma Clinical Coordinator and Neurosurgery Clinical Specialist to
update the status of the service activities, agendas, QA review, registry, etc.

7. Meets at least biweekly with the Trauma Medical Director to discuss the status of the
service activities, issues, solutions, etc.

8. Assists in the preparation of reports as requested by Administration.

15
Community and Liaison

1. Maintains and supports inservice and community outreach programs related to care of
the Neurosurgery patient for medical, nursing, and EMS communities, as well as
nonmedical personnel.

2. Provides consultation on Neurosurgery care and Neurosurgery Service development to

outreach areas as requested by Administration.

3. Maintains liaison with local EMS agencies through appropriate committee

participation.

4. Maintains liaison with other Neurosurgery Centers in the State through participation in
the ..... Trauma Institute, conferences and meetings.

Education and Research

1. Assists in the review of data through the Trauma Registry program in accordance with
national and local standards. Where appropriate, participates in recognized statistical
analysis programs.

2. Assesses desirability/need for formal or informal research program. Supports requests

for data acquisition and analysis.

3. Directs program development for...... Neurosurgery Team member education.

4. Participates in other education programs.

Qualifications

1. Licensed to practice medicine in the State of .....

2. Board certified by the American Board of Neurological Surgery.

3. Training in accredited Neurosurgery program and/or extensive documented experience

in the care of Neurosurgery patients.

4. ACS membership, experience in management, research and teaching desirable.

5. Member of the Medical Staff of the system hospitals.

16
IN WITNESS WHEREOF, the duly authorized offices of the parties have executed this
AMENDMENT, as of the respective dates written below.

CONTRACTOR: FACILITY/Hospital:
LLC d/b/a/ The Medical Center..

____________________________ By:______________________________________
Chief Executive Officer, as VP of Facility

By:_______________________________________
Facility Ethics & Compliance Officer

17
SAMPLE CONTRACT #2
 PROFESSIONAL NEUROSURGICAL TRAUMA SERVICES AGREEMENT

THIS PROFESSIONAL NEUROSURGICAL TRAUMA SERVICES AGREEMENT

(this “Agreement”) is entered into and effective .........., 20.. (the “Effective Date”), by and
between ......................................... and .......... NEUROSURGERY ASSOCIATES, P.A., a
(state) professional corporation (“Group”).

Background Statement

Hospital’s constant objectives are to improve the quality of patient care; to utilize
Hospital’s facilities, equipment and employees efficiently and effectively; and to minimize the
costs of medical care. In pursuit of these objectives in the area of neurosurgical trauma
services, Hospital desires to secure the services of a group of qualified physicians to provide
certain professional services and medical supervision and direction for Hospital’s Trauma
Service (the “Trauma Service”). Group employs physicians who are qualified by virtue of
background, education, training and experience to provide professional neurosurgical trauma
services and medical supervision and direction for the Trauma Service (the “Specialists”).

Statement of Agreement

NOW, THEREFORE, in consideration of the mutual promises contained in this

Agreement, and other good and valuable consideration, the receipt and sufficiency of which
are hereby acknowledged, the parties hereto agree as follows:

1. Term and Renewal. The initial term of this Agreement shall begin on ......,
20.., and shall end at midnight on ........., 20.. (the “Initial Term”). After the Initial Term, this
Agreement shall automatically renew for successive two (2) year terms (each, a “Renewal
Term”), unless either party gives the other party at least twelve (12) months written notice
prior to the end of the Initial Term, or the then current Renewal Term, of its intention not to
renew this Agreement. Any such written notice shall specify the reason for nonrenewal. The
Initial Term and the Renewal Terms, if any, shall be referred to herein as the “Term”.

2. Services of Group. Group agrees to assume the following responsibilities

and perform the following duties:

(a) Provide Specialists who are employees of Group and are listed on
Exhibit A attached hereto as neurosurgery attending physicians to Hospital to provide the
following professional neurosurgical trauma services (the “Neurosurgical Trauma Services”)
to patients of the Trauma Service:

(i) Consultation, evaluation, admission, treatment and

neurosurgery services for any Trauma Service patient during
such patient’s initial hospitalization;
(ii) Neurosurgery for any patient originally admitted to Hospital as
a Trauma Service patient who is readmitted to Hospital within
the post-operative global fee period;
(iii) Neurosurgical outpatient follow-up care provided to Trauma
Service patients upon discharge from Hospital; and

1
 (iv) Other neurosurgical inpatient or outpatient treatment related to
the traumatic injury of a Trauma Service patient.

As used herein, Neurosurgical Trauma Services means those services customarily provided
by neurosurgeons in tertiary care institutions in the United States, and includes without
limitation the application and insertion of any invasive cranial monitoring. The Trauma
Service attending physician (the “Trauma Attending”) or the Trauma Service chief resident
shall notify Specialists when a patient of the Trauma Service requires Neurosurgical Trauma
Services. If at any time Group or any Specialist determines in good faith that the Trauma
Attending has requested Neurosurgical Trauma Services inappropriately or has failed to
request Neurosurgical Trauma Services when necessary, then upon Group’s request, the
Hospital’s Trauma Services Director shall work cooperatively with Group to assure that
Group’s services are appropriately utilized under this Agreement.

(b) Provide Neurosurgical Trauma Services twenty-four (24) hours a day,

seven (7) days per week, and provide to Hospital a back-up call schedule at all times.

(c) Cause Specialist(s) to be present for any neurosurgery performed on

Trauma Service patients and to attend in the operating room and in the perioperative period
when neurosurgical care is being provided to patients requiring neurosurgical care.

(d) Cause Specialists to adhere to all policies and procedures required to

maintain Hospital’s accreditation as a Level I Trauma Center by the State of ............ as
specified in this Agreement and in the criteria of the American College of Surgeons, including
Specialist response within thirty (30) minutes of notification by the Trauma Service attending
physician, or such physician’s designee, as required by the ..... Administrative Code for Level
I Trauma Center Criteria.

(e) Cause Specialists to cooperate with the Trauma Service attending

physician to coordinate all calls regarding the acceptance and transfer of patients meeting
multiple trauma criteria.

(f) Cause Specialists to respond promptly in writing to all requests from

Hospital’s Trauma Outcomes Committees, both pediatric and adult, which are responsible for
Trauma Service Quality Assurance; and cause at least one (1) Specialist to be in attendance
at not less than seventy-five percent (75%) of the meetings of such Trauma Outcomes
Committees.

(g) Require the Specialists, while providing Neurosurgical Trauma

Services hereunder, (i) to permit physician residents from the Hospital’s Residency Training
Programs to observe and receive instruction from Specialists within the normal course of
Specialists’ provision of clinical care; and (ii) to participate in clinical research studies
mutually agreed upon by Hospital and Group and, if required, approved by Hospital’s
Institutional Review Board. Group recognizes and acknowledges that the treatment of
patients admitted to the Trauma Service is an integral aspect of Hospital’s Residency
Training Programs and clinical research activities.

(h) Require each Specialist to maintain continuing medical education

(“CME”) in trauma surgery, which CME shall include the equivalent of sixteen (16) CME
credits each year in trauma-related topics. Each year Group shall submit to Hospital
documentation evidencing each Specialist’s CME credits for such year. Group shall cause at

2
least one (1) Specialist to be in attendance at not less than fifty percent (50%) of the monthly
multidisciplinary trauma conferences offered each year by Hospital and to report to the other
Specialists regarding each such conference that a Specialist attends.

(i) Instruct and cause the Specialists to comply with the following: (i)
Medical Staff (as defined below) rules, regulations and policies; (ii) rules, regulations and
policies of various accreditation and governmental agencies applicable to Hospital or to the
Trauma Service; (iii) and applicable state and federal laws and regulations, as they may be
amended from time to time in providing Neurosurgical Trauma Services hereunder. Group
shall also ensure that each of its employees providing services under this Agreement to or at
Hospital complies with the professional ethics and standards of conduct required by relevant
State Licensing Boards and of his or her professional organization.

(j) Cooperate with the Hospital’s Trauma Services Director, or his

designee, and provide input to such Trauma Services Director with respect to the clinical
management and triage of patients requiring Neurosurgical Trauma Services. Through such
cooperation, Hospital and Group desire to achieve an allocation of available beds, services
and resources that most effectively utilizes the facilities available to Hospital.

3. Additional Agreements and Covenants of Group. Group shall neither hire

any person to provide services under this Agreement or to work on Hospital’s premises nor
hire any person as a Hospital employee without the prior written approval of the Senior Vice
President/Chief Operating Officer of Hospital. Notwithstanding the foregoing, nothing in this
Agreement shall be construed to restrict Group’s right or ability to hire Group employees.
Group hereby represents, warrants, covenants and agrees that no individual provided at any
time to Hospital under this Agreement shall have been (i) convicted of a criminal offense
related to healthcare; or (ii) debarred or excluded from Federal program participation.

4. Qualifications of Specialists. Each Specialist assigned by Group to provide

services pursuant to this Agreement shall at all times:

(a) have a valid and unrestricted license to practice medicine in the State
of .......

(b) be certified by the American Board of Neurological Surgery (the

“Board”), or be eligible for certification by the Board at the time Specialist begins providing
services hereunder and within three (3) years of such time and at all times thereafter be
certified by the Board; provided, however, that if the Board delays administering the
examination for certification for any reason unrelated to the qualifications of Specialist, and
as a result Specialist is not certified within the three (3) year period required hereunder, then
such time period shall be extended for the same period of time as the delay by the Board;

(c) maintain in good standing active membership and clinical privileges on

Hospital’s Medical and Dental Staff (the “Medical Staff”) and Hospital’s Department of
Neurosurgery (the “Department”) in accordance with the Medical Staff Bylaws;

(d) comply with the bylaws, rules and regulations, policies, procedures
and directives of Hospital and the Medical Staff; and

3
 (e) have a current narcotics license and number issued by the appropriate
governmental agency or agencies.

If at any time any Specialist fails to meet any of the above requirements,
Hospital shall provide written notice to Group of such failure, specifying the requirement(s)
that the Specialist failed to meet. Group shall, upon receipt of such notice, promptly, and in
any event within a period of five (5) business days following receipt of such notice, suspend
such Specialist from all duties on the Trauma Service pursuant to this Agreement and
provide an interim Specialist who meets the above requirements as soon as reasonably
possible, or impose such other restrictions as may be reasonably approved by Hospital.

5. Duties of the Hospital

(a) Hospital shall make available to Group such space, facilities, supplies,
materials, equipment and utilities as are reasonably available or attainable, adequate and
appropriate to enable Group and the Specialists to perform those services required under
this Agreement. Commencing January 1, 200..., Hospital shall make available to Group a
Neurosurgical Trauma Services operating room daily between the hours of 1:00 P.M. and
8:00 P.M. standard time; provided, however, that Group assist Hospital to recruit and retain
adequate and appropriate personnel, not currently employed at Hospital or any other hospital
owned or operated by......., to staff such operating room during such time period. If at any
time Group determines in good faith that the Hospital is failing to satisfy the requirements of
the foregoing sentences, then upon Group’s request, the Senior Vice President/Chief
Operating Officer of Hospital shall meet with Group to discuss Hospital’s performance under
this Agreement.

(b) Hospital shall provide Group adequate and timely documentation of

Hospital’s services provided to patients of the Trauma Service necessary to enable Group to
conduct its billing and collection operations for professional fees. Hospital agrees to provide
the Specialists with access to Hospital’s dictation system.

(c) The Hospital’s Trauma Services Director, or his designee, shall

cooperate with Group while providing, and shall solicit Group’s input regarding, the clinical
management and triage of patients requiring Neurosurgical Trauma Services. Through such
cooperation, Hospital and Group desire to achieve an efficient allocation of available beds,
services and resources that most effectively utilizes the facilities available to Hospital. The
parties hereto anticipate that Group will designate Specialist(s) to serve in the yet-to-be-
defined role of Neurosurgical Trauma Services Triage Director. Hospital, Group and the
Hospital’s Trauma Services Director will initiate immediate efforts to define and implement
this role during the Term of this Agreement.

6. Compensation. As consideration for the services of Group provided

hereunder, Hospital shall pay Group the compensation described in Exhibit B attached
hereto. Group shall have the sole responsibility for compensating Specialists and other
employees of the Group.

7. Medical Records

(a) Group shall, and shall require each Specialist to, maintain complete
medical records relating to its responsibilities under this Agreement in compliance with the

4
applicable requirements of the Medical Staff Bylaws and any federal or State licensing entity
with jurisdiction and shall afford the Hospital reasonable access thereto.

(b) All medical records pertaining to the provision of Neurosurgical

Trauma Services at Hospital shall be the property of Hospital and shall at all times be freely
available for the use of Group and the Specialists; provided, however, that the original of
such records may not be removed from Hospital premises without Hospital’s consent. Upon
the expiration or termination of this Agreement, Hospital will retain custody and control of
such patient medical records.

8. Billing, Documentation and Reimbursement Requirements

(a) Group shall bill each patient of the Trauma Service, or such patient’s
insurer or representative, for Neurosurgical Trauma Services provided by Specialists to each
such patient pursuant to this Agreement.

(b) Group shall record, maintain and provide to Hospital all reasonable
information and documentation that Hospital may require in order to secure reimbursement
from federal or State agencies, intermediaries, carriers or other third-party reimbursers or
patients for services provided to inpatients and outpatients hereunder. This information and
documentation shall include the recording and maintenance by the Specialists and other
Group professional employees, if any, of records of Neurosurgical Trauma Services
provided, of time spent providing Neurosurgical Trauma Services, and such other information
as may be requested by Hospital or such third-party payors. If (i) Hospital loses income from
any third-party reimburser as a direct result of Group’s failure to maintain and provide the
records required under this Agreement by Hospital; (ii) Hospital provides written notice to
Group of Group’s specific failure causing such loss of income and the amount of such lost
income; and (iii) Group fails or refuses to correct such failure within thirty (30) days of receipt
of such notice, then Group shall reimburse Hospital for any such lost income, and Hospital
may reduce its payment to Group for services provided to Hospital by an amount equal to the
amount of such lost income. Hospital shall record, maintain and provide to Group all
reasonable information and documentation that Group may require in order to secure
reimbursement from federal or State agencies, intermediaries, carriers or other third-party
reimbursers or patients for services provided to inpatients or outpatients by Hospital
hereunder.

(c) The Group shall require each Specialist to comply with federal
documentation guidelines when supplying supporting documentation for Neurosurgical
Trauma Services.

(d) Until the expiration of four (4) years following the furnishing of goods or
services pursuant to this Agreement, Group shall, and shall require each Specialist to, make
available, upon written request, to the Secretary of the Department of Health and Human
Services or, upon request, to the Comptroller General of the United States, or any of their
duly authorized representatives, the contract, books, documents, and records of the
Specialists that are necessary to certify the nature and extent of Group’s costs under this
Agreement. If Group carries out any of the duties of this Agreement through a subcontract
with a value or cost of $10,000 or more over a twelve-month period, with a related
organization, such subcontract shall contain a clause to the effect that until the expiration of
four (4) years after the furnishing of goods or services pursuant to such subcontract, the
related organization shall make available, upon written request, to the Secretary of the
Department of Health and Human Services, or, upon request, to the Comptroller General of
the United States, or any of their duly authorized representatives, the subcontract and books,

5
documents, and records of such related organization that are necessary to verify the nature
and extent of the subcontractor’s costs.

(e) If (i) Group loses income from any third party-reimburser as a direct result of
Hospital’s failure to maintain and provide to Group the documentation required in Section
5(b) of this Agreement; (ii) group provides written notice to Hospital of Hospital’s specific
failure causing such loss of income and the amount of such lost income; and (iii) Hospital
fails or refuses to correct such failure within thirty (30) days of receipt of such notice, then
Hospital shall reimburse Group for any such income.

9. Insurance

(a) Group shall obtain and maintain in force throughout the duration of this
Agreement professional liability insurance providing general and physician’s professional
liability malpractice insurance coverage for at least $1,000,000 for any one occurrence and
$3,000,000 annual aggregate. The Group’s professional liability insurance shall cover each
Specialist and all other personnel of Group assigned by the Group to provide services under
this Agreement. Group shall supply Hospital with a certificate of insurance evidencing such
coverage. This insurance shall cover each Specialist in the event of a claim or lawsuit for
professional negligence for any action or omission committed by a Specialist pursuant to this
Agreement. Group shall immediately notify Hospital in writing if it receives notice of
cancellation, termination, reduction or nonrenewal of the insurance required in this Section. If
such insurance is canceled or terminated and if for any reason Group is unable to secure or
maintain the insurance coverage required by this Section, Hospital shall have the option,
upon ten (10) days’ written notice, to declare this Agreement temporarily suspended and, in
the event of such suspension, Group shall temporarily discontinue services, in which case
the parties shall be relieved of their respective obligations under this Agreement, except that
Hospital may require the Group to continue to meet the emergency needs of Trauma Service
patients for which the services of other qualified physicians cannot reasonably be obtained.
Should this Agreement be temporarily suspended, it shall be immediately reinstated, together
with the respective obligations of the parties, at the time Group provides Hospital satisfactory
evidence of insurance coverage required by this Section. Group agrees to save and hold
harmless the Hospital from any liability for any negligent act or omission of Group or any
Specialist.

(b) ....... shall, at its own expense, through self-insurance or through insurance
contracts, maintain at all times during the Term of this Agreement professional liability
insurance for its employees in a minimum amount of $1,000,000 per occurrence, $5,000,00
in the aggregate, and comprehensive general public liability insurance, with respect to the
business carried on, in or from Hospital’s facilities in such amounts as ....... deems
appropriate. Upon Group’s request, ....... shall supply Group with evidence of such coverage.
...... shall immediately notify Group in writing upon the cancellation, termination, reduction or
nonrenewal of the insurance required in this Section.

10. Independent Contractors. The sole relationship between the parties hereto
is that of independent contractors. This Agreement is not intended, nor shall it be construed,
to create any partnership, employment, agency or joint venture relationship between Hospital
or Group or the employees of Group. Group is independent and expressly disclaims, both for
itself and its employees, any entitlement to Hospital’s employee benefits. Hospital is neither
practicing medicine nor does it intend to control or direct the practice of medicine by Group’s
employees.

6
 11. Responsibility for Taxes. Group shall be solely responsible for and shall
hold Hospital harmless from the payment of any and all taxes, penalties, assessments and
interest of whatever kind that may be due or assessed by any governmental entity or agency
arising out of any monies earned by Group or benefits received by and paid to Group for
services rendered by Group to Hospital pursuant to this Agreement. Hospital shall be solely
responsible and shall hold Group harmless from payment of any and all taxes, penalties,
assessments and interest of whatever kind that may be due or assessed by any
governmental entity or agency arising out of any monies earned by Hospital or benefits
received by Hospital pursuant to this Agreement. The obligations of the parties pursuant to
this Section shall survive termination of this Agreement.

12. Termination. In the event of a breach of the terms of this Agreement by

either party which is not corrected within thirty (30) days following written notice thereof by
the other party (the “Nonbreaching Party”), this Agreement may be terminated immediately
by the Nonbreaching Party. In addition, Hospital shall have the right to terminate this
Agreement immediately upon the occurrence of any of the following: (i) any restrictions or
limitations are imposed by any governmental authority having jurisdiction over Group to such
an extent that Group cannot engage in the professional practice of neurosurgery as required
hereunder; or (ii) any Specialist (A) ceases to be qualified as required under Section 4 of this
Agreement and the Group fails to remove such Specialist within the time period provided in
Section 4; (B) is found guilty of unprofessional or unethical conduct by any Board, institution,
organization or professional society having any privilege or right to pass upon such conduct;
(C) commits a felony; or (D) commits any offense involving moral turpitude, including but not
limited to fraud, theft or embezzlement. Notwithstanding the foregoing, if a specific Specialist
or other professional employee of the Group is responsible for an event of default set forth in
subsections (ii) (B), (C) or (D) above, then Group may cure such default by removing such
Specialist from all duties at the Trauma Service pursuant to this Agreement and providing, as
soon as reasonably possible, a replacement Specialist who satisfies the requirements of this
Agreement, or imposing such other restrictions as may be reasonably approved by Hospital
for purposes of curing such defaults.

13. Changes in Law

(a) Legal Event: Consequences. Notwithstanding any other provision of

this Agreement, if the governmental agencies that administer the Medicare, Medicaid, or
other federal programs (or their representatives or agents), or any other federal, State or
local governmental or nongovernmental agency, or any court or administrative tribunal
passes, issues or promulgates any law, rule, regulation, standard, interpretation, order,
decision or judgment, including but not limited to those relating to any regulations pursuant to
State or federal anti-kickback or self-referral statutes (collectively or individually, a “Legal
Event”), which, in the good-faith judgment of one party (the “Noticing Party”), materially and
adversely affects either party’s licensure, accreditation, certification, or ability to refer, to
accept any referral, to bill, to claim, to present a bill or claim, or to receive payment or
reimbursement from any federal, state or local governmental or non-governmental payor, or
which subjects the Noticing Party to a risk of prosecution or civil monetary penalty, or which,
in the good faith of the Noticing Party, indicates a rule or regulation with which the Noticing
Party desires further compliance, or if in the good faith opinion of legal counsel to either party
any term or provision of this Agreement could trigger a Legal Event, then the Noticing Party
may give the other party notice of intent to amend or terminate this Agreement in accordance
with the following subsections.

7
 (b) Notice Requirements. The Noticing Party shall give notice to the other
party together with an opinion of legal counsel setting forth the following information:

(i) The Legal Event(s) giving rise to the notice;

(ii) The consequences of the Legal Event(s) as to the Noticing Party;
(iii) The Noticing Party’s intention to either:

(A) Terminate this Agreement due to unacceptable risk of

prosecution or civil monetary penalty; or
(B) Amend this Agreement, together with a statement that the
purpose thereof is one or more of the following:

1. To further comply with any statutory provisions or

rules or regulations created or affected by Legal
Event(s); and/or
2. To satisfy any licensure, accreditation or certification
requirements created or affected by the Legal Event(s);
and/or
3. To eliminate or minimize the risk of prosecution or
civil monetary penalty.

(iv) The Noticing Party’s proposed amendment(s); and

(v) The Noticing Party’s request for commencement of the
Renegotiation Period (as defined below).

(c) Renegotiation Period: Termination. In the event of notice under either

subsection (b)(iii)(A) or (b)(iii)(B) above, the parties shall have thirty (30) days from the giving
of such notice (the “Renegotiation Period”) within which to attempt to amend this Agreement
in accordance with the Noticing Party’s proposal (if any) or otherwise as the parties may
agree. If this Agreement is not so amended within the Renegotiation Period, this Agreement
shall terminate as of midnight on the thirtieth (30th) day after said notice was given. Except as
otherwise required by applicable law, any amounts owing to either party hereunder shall be
paid, on a pro rata basis, up to the date of such termination, and any obligation hereunder
that is to continue beyond expiration or termination shall so continue pursuant to its terms. All
opinions of legal counsel presented by the Noticing Party hereunder, and any corresponding
opinions given by the other party in response, shall be deemed confidential and given solely
for the purposes of renegotiation and settlement of a potential dispute, and shall not be
deemed disclosed so as to waive any privileges otherwise applicable to said opinions.

14. Confidentiality. Except as required by law or as necessary to perform its

obligations hereunder, Group agrees not to disclose the terms of this Agreement or any
information relating to Hospital’s operations without the express written consent of Hospital.
In performing duties and obligations under this Agreement, each member of Group and
Hospital shall comply with, and each shall cause its employees to comply with, applicable
state and federal laws and regulations relating to the security and protection of health
information, including without limitation the Health Insurance Portability and Accountability
Act of 1996 and regulations promulgated thereunder, as they may be amended from time to
time.

8
 15. No Referrals. The parties agree that this Agreement shall not be interpreted
in any manner so as to require the referral of patients by Group or Specialists to Hospital, or
by Hospital to Group or Specialists, in contravention of any applicable law or regulation.

16. Miscellaneous Provisions

(a) All section and item headings are inserted for convenience only and do
not expressly or by implication limit, define, or extend the specific terms of the section so
designated.

(b) This Agreement and all Exhibits incorporated by reference contain the
entire understanding of the parties relating to the matters referred to herein, and shall be
amended only by written instrument signed by the parties to this Agreement.

(c) If any provision of this Agreement shall for any reason be held invalid,
illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not
affect any other provision of this Agreement, but this Agreement shall be construed as if such
invalid, illegal, or unenforceable provision had never been contained herein, unless the
invalidity of any such provision substantially deprives either party of the practical benefits
intended to be conferred by this Agreement.

(d) This Agreement shall be construed in accordance with and governed

by the laws of the State of ........, without giving effect to the conflict-of-laws provisions
thereof.

(e) Whenever a notice is required to be given in writing under this

Agreement, such notice shall be given in person or by certified mail, return receipt requested.

(f) Group may not assign any of Group’s rights or obligations hereunder
without the prior written consent of Hospital.

(g) The failure of either party to promptly exercise a right hereunder, or to

seek a remedy available hereunder because of a breach of this Agreement, shall not be
construed as a waiver of that right or a waiver of any remedy for that breach or any future
breach of this Agreement.

(h) Nothing in this Agreement shall be construed as creating or giving rise

to any rights in any third parties or any persons other than the parties hereto.

(i) Whenever used herein, the masculine pronoun shall include the
feminine and neuter pronouns, and the singular shall include the plural, and the plural the
singular.

9
 IN WITNESS WHEREOF, the parties have executed this Agreement the day and year
first written above.

(Hospital)

By:______________________________________________
Name: __________________________________________
Title: ___________________________________________

.......... NEUROSURGERY ASSOCIATES, P.A.

By: _____________________________________________
Name: __________________________________________
Title: ___________________________________________

The Specialists below hereby execute this Agreement:

_________________________________ ______________________________________
John Doe, M.D. John Doe, M.D.

_________________________________ ______________________________________
John Doe, M.D. John Doe, M.D.

_________________________________ ______________________________________
John Doe, M.D. John Doe, M.D.

_________________________________ ______________________________________
John Doe, M.D. John Doe, M.D.

10
 EXHIBIT A

Specialists

John Doe, M.D.

John Doe, M.D.

John Doe, M.D.

John Doe, M.D.

John Doe, M.D.

John Doe, M.D.

EXHIBIT B

Compensation

(Attach agreement between hospital and group)

11
 PROFESSIONAL MEDICAL DIRECTOR SERVICES AGREEMENT

THIS PROFESSIONAL MEDICAL DIRECTOR SERVICES AGREEMENT (this

“Agreement”) is entered into as of the 1st day of ........., 20.., by and between.........
HOSPITAL AUTHORITY (the “Hospital”) and ...... NEUROSURGERY ASSOCIATES, P.A., a
(state) professional corporation (“Group”).

Background Statement

The Hospital desires to engage the services of a physician to provide professional

direction and supervision with respect to neurosurgical trauma to the Hospital’s Trauma
Service. Group employs physicians who are qualified by virtue of background, education,
training and experience to provide such services (the “Physicians”), and Group desires to
provide such services to Hospital pursuant to the terms and conditions of this Agreement.
The neurosurgical trauma section of the Hospital’s Trauma Service shall be referred to
herein as the “Neurosurgical Trauma Section”.

Hospital and Group entered into a Professional Neurosurgical Trauma Services

Agreement as of ..........., 20.. (the “Trauma Services Agreement”), pursuant to which Group
provides neurosurgical trauma services to Hospital.

Statement of Agreement

NOW, THEREFORE, in consideration of the mutual promises of the parties hereto

and other good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, the parties agree as follows:

1. Term. The initial term of this Agreement shall be for a period of one (1) year,
beginning on ......., 20.., and ending at midnight on ......, 20... This Agreement may be
renewed for additional one-year terms upon written amendment signed by the parties.

2. Services of Group. Group agrees to provide a Physician satisfactory to

Hospital who is an employee of Group to assume the responsibilities and perform the duties
described in Exhibit B attached hereto and incorporated herein by reference. The parties
estimate that Physician shall devote approximately five (5) to six (6) hours per month to the
performance of such duties. Group shall cause Physician to deliver to Hospital each month a
Service Documentation Report in the form attached hereto as Attachment B-1 (the “Service
Documentation Report”). Group shall cause Physician to deliver Service Documentation
Report to Hospital within ten (10) days of the end of each month that Physician provides
services hereunder.

3. Qualifications of Physician. At all times during the term of this Agreement,

the Physician assigned by Group to provide services pursuant to this Agreement shall: (a)
hold a license to practice medicine in the State of ....; (b) maintain active medical staff
privileges and membership in good standing on the Hospital’s Medical Staff (“Medical Staff”)
and Hospital’s Department of Neurosurgery (“Department of Neurosurgery”); (c) have a
current narcotics license and number issued by the appropriate governmental agency or
agencies; and (d) be certified by the American Board of Neurological Surgery (the “Board”)
and remain current with that certification through periodic continuing medical education and
examination as required by the Board.

12
 4. Compensation. As consideration for the services of Group provided to
Hospital hereunder, Hospital shall pay Group compensation according to Exhibit A attached
hereto and incorporated herein by reference.

5. Hospital Obligations. The Hospital shall provide the facilities, equipment,

support personnel and supplies reasonably necessary for Physician to provide the services
required of Physician under this Agreement. Hospital is neither practicing medicine nor does
it intend to control or direct the practice of medicine by Physician.

6. Policies and Procedures: Personnel Matters. Group agrees, and shall

require Physician to, abide by the rules, policies and procedures of Hospital and the
Department of Neurosurgery, all as may be amended from time to time, and the
requirements of various governmental or accrediting agencies applicable to Hospital or the
Department of Neurosurgery. These rules, policies, and procedures may include, among
other things, standards of care and professional protocols applicable to ......... and Hospital
outpatient facilities. All such rules, policies and procedures are hereby incorporated by
reference and made a part of this Agreement. Notwithstanding the foregoing, a revision or
amendment to a rule, policy or procedure of ....... or Hospital that would result in a material
change in the business arrangement agreed to by Group herein shall not be incorporated
and made a part of this Agreement without the consent of Group. Group acknowledges and
agrees that nothing in this Agreement shall be construed to authorize Group or Physician to
hire any person on behalf of Hospital as a Hospital employee.

7. Confidentiality of Information. Group agrees not to disclose, and to require

Physician not to disclose, any information relating to Hospital or Neurosurgical Trauma
Section operations to persons other than: (a) members of the Medical Staff; (b) any state
licensing board; (c) the Joint Commission on Accreditation of Healthcare Organizations; or
(d) any third-party reimbursement entity having the right and need to know, without the
express written consent of Hospital, unless otherwise ordered by a court of law. This Section
7 shall survive the expiration or termination of this Agreement for any reason.

8. Billing. Group agrees that neither Group nor Physician will bill for any
physician services provided pursuant to this Agreement, and that Group’s sole compensation
for services provided pursuant to this Agreement shall be as provided in Exhibit A.

9. Termination. This Agreement may be terminated as follows:

a. A party hereto may terminate this Agreement immediately in the event

of a material breach of any term of this Agreement by the other party that is not corrected
within ten (10) days following written notice thereof.

b. A party hereto may terminate this Agreement upon ninety (90) days
written notice to the other party.

c. The Hospital shall have the right to terminate this Agreement

immediately “for cause” if Physician: (i) ceases to be qualified as required in Section 3 or
has Physician’s Medical Staff or Department of Neurosurgery membership or privileges
suspended or reduced to an extent that Physician is thereby unable to provide the services
described in Exhibit B; (ii) commits any felony; (iii) commits any offense involving moral
turpitude, including but not limited to fraud, theft or embezzlement; (iv) commits professional
malpractice sufficient to indicate that Physician is not competent to practice medicine; or (v)
exhibits significant misconduct or willful inattention to the economic or ethical welfare of the
Neurosurgical Trauma Section, the Hospital, or .......

13
 d. The parties agree that if this Agreement is terminated by either party
for cause under this Section during the first year of this Agreement, then the parties shall not
do either of the following until at least one (1) year from the date of the beginning of the initial
term: (i) enter into a services agreement with each other for services similar to those
provided hereunder; or (ii) negotiate with each other the terms of a services agreement for
services similar to those provided hereunder.

10. Professional Liability Insurance. Group shall maintain professional liability

insurance with a limit of not less than $1,000,000.00 per occurrence and with $3,000,000.00
aggregate limit. Group shall furnish Hospital a certificate of insurance as proof of this
coverage. This insurance shall cover Physician in the event of a claim or lawsuit for
professional negligence for any action or omission committed by Physician pursuant to this
Agreement. Group shall immediately notify the Hospital in writing if Group receives notice of
cancellation, termination, reduction or nonrenewal of the insurance required in this Section. If
such insurance is canceled or terminated and if for any reason Group is unable to secure or
maintain the insurance coverage required by this Section, the Hospital shall have the option,
upon ten (10) days’ written notice, to declare this Agreement temporarily suspended and, in
the event of such suspension, Group shall temporarily discontinue services, in which case
the parties shall be relieved of their respective obligations under this Agreement. Should this
Agreement be temporarily suspended, it shall be immediately reinstated, together with the
respective obligations of the parties, at the time Group provides the Hospital satisfactory
evidence of insurance coverage required by this Section. Group agrees to save and hold
harmless the Hospital from any liability for any negligent act or omission of Group or
Physician. Hospital agrees to save and hold harmless the Group and Physician from any
liability for any negligent act or omission of the Hospital.

11. Records Access. Until the expiration of four (4) years after the furnishing of
any services by Group hereunder, Group shall make available, upon written request, to the
Secretary of the Department of Health and Human Services or, upon request, to the
Comptroller General, or their duly authorized representatives, this Agreement and the books,
documents, and records of Group that are necessary to certify the nature and extent of the
costs of this Agreement. If Group carries out any of the duties of this Agreement through a
subcontract (with a value or cost of $10,000 or more over a twelve-month period) with a
related organization, such subcontract shall contain a provision substantially identical to this
Section, requiring such subcontractor to make similar agreements, books, documents, and
records available to the same parties as must Group for the same time period for the
purpose of verifying the nature and extent of such costs.

12. Independent Contractor. The sole relationship between the parties hereto is
that of independent contractors. This Agreement is not intended, nor shall it be construed, to
create any partnership, employment, agency or joint venture relationship between the
Hospital and Group. Group is independent and expressly disclaims, both for itself and for its
employees, any entitlement to the Hospital’s employee benefits. The Hospital is neither
practicing medicine nor does it intend to control or direct the practice of medicine by
Physician.

14
 13. Responsibility for Taxes. Group shall be solely responsible for and shall
hold the Hospital harmless from the payment of any and all taxes, penalties, assessments
and interest of whatever kind that may be due or assessed by any governmental entity or
agency arising out of any monies earned by Group or benefits received by and paid to Group
for services rendered by Group to the Hospital pursuant to this Agreement. The Hospital
shall be solely responsible and shall hold Group harmless from the payment of any and all
taxes, penalties, assessments and interest of whatever kind that may be due or assessed by
any governmental entity or agency arising out of any monies earned by the Hospital or
benefits received by the Hospital pursuant to this Agreement. These obligations shall survive
termination of this Agreement.

14. Changes in Law

(a) Legal Event: Consequences. Notwithstanding any other provision of

this Agreement, if the governmental agencies that administer the Medicare, Medicaid or
other federal programs (or their representative or agents), or any other federal, state or local
governmental or nongovernmental agency, or any court or administrative tribunal passes,
issues or promulgates any law, rule, regulation, standard, interpretation, order, decision or
judgment, including but not limited to those relating to any regulations pursuant to state or
federal anti-kickback or self-referral statutes (collectively or individually, “Legal Event”),
which, in the reasonable and good-faith judgment of one party (the “Noticing Party”) (and
supported by the written opinion of independent legal counsel as required in (b) below),
draws into question the terms of this Agreement in a manner that may materially and
adversely affect either party’s licensure, accreditation, certification, or ability to refer, to
accept any referral, to bill, to claim, to present a bill or claim, or to receive payment or
reimbursement from any federal, state or local governmental or non-governmental payor, or
that may subject the Noticing Party to a substantial risk of prosecution or civil monetary
penalty, then the Noticing Party may give the other party notice of intent to amend or
terminate this Agreement in accordance with the next subparagraph.

(b) Notice Requirements. The Noticing Party shall give notice to the other
party together with the following information:

(i) A description of the Legal Event(s) giving rise to the notice;

(ii) The written opinion of independent legal counsel with expertise in
the area of healthcare law and a national practice specializing in
healthcare law, describing the Legal Event and the consequences or
potential consequences of the Legal Event(s) as to the Noticing Party;
(iii) the Noticing Party’s intention to either:

(A) amend this Agreement, together with a description of the

terms of such amendment and the purposes thereof; or
(B) if the documentation from legal counsel referred to in item
(ii) above states that no amendment to this Agreement can
reasonably avoid the material and adverse consequences of
the Legal Event(s), terminate this Agreement.

(c) Renegotiation Period: Termination. Upon the giving of a notice

pursuant to subsection (b) above, the parties shall have sixty (60) days from the giving of
such notice to attempt to amend this Agreement in accordance with the Noticing Party’s
proposal (if any) or otherwise as the parties may agree. If this Agreement is not so amended
within such 60-day period, this Agreement shall terminate as of midnight on the 60th day after
said notice was given. Except as otherwise required by applicable law, any amounts owing to
either party hereunder shall be paid, on a pro rata basis, up to the date of such termination,
15
and any obligation hereunder that is to continue beyond expiration or termination shall so
continue pursuant to its terms. All communications presented by the Noticing Party
hereunder, and any communications given by the other in response, shall be deemed
confidential and given solely for the purposes of renegotiation and settlement of a potential
dispute, and shall not be deemed disclosed so as to make any admission or waive any
privileges otherwise applicable thereto.

15. Miscellaneous Provisions

A. All section and item headings are inserted for convenience only and do not
expressly or by implication limit, define or extend the specific terms of the section so
designated.

B. This Agreement and all Exhibits incorporated by reference contain the entire
understanding of the parties relating to the matters referred to herein, and shall be
amended only by written instrument signed by the parties to this Agreement.

C. If any provision of this Agreement shall for any reason be held invalid, illegal
or unenforceable in any respect, such invalidity, illegality or unenforceability shall not
affect any other provision of this Agreement, but this Agreement shall be construed
as if such invalid, illegal or unenforceable provision had never been contained herein,
unless the invalidity of any such provision substantially deprives either party of the
practical benefits intended to be conferred by this Agreement.

D. This Agreement shall be construed in accordance with and governed by the

laws of the State of ......, without giving effect to the conflict-of-laws provisions thereof.

E. Whenever a notice is required to be given in writing under this Agreement,

such notice shall be given in person or by certified mail, return receipt requested.

F. Neither party may assign any of its rights or obligations hereunder without the
prior written consent of the other party.

G. The failure by either party to promptly exercise a right hereunder, or to seek a

remedy available hereunder because of a breach of this Agreement, shall not be
construed as a waiver of that right or a waiver of any remedy for that breach or any
future breach of this Agreement.

H. Nothing in this Agreement shall be construed as creating or giving rise to any

rights to any third parties or any persons other than the parties hereto.

I. Whenever used herein, the masculine pronoun shall include the feminine and
neuter pronouns, and the singular shall include the plural, and the plural the singular.

16
 IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be
executed the day and year first above written at (City, State).

......NEUROSURGERY ASSOCIATES, P.A.

By: ________________________________________
John Doe, M.D.
Its: President

17
 EXHIBIT A
COMPENSATION

As consideration for the services provided hereunder, Hospital shall pay Group at the
rate of ......... ($.00) per hour for services provided by the Physician; provided, however, that
the total annual compensation paid to Group hereunder shall not exceed ........ ($.00).
Hospital shall pay Group on a monthly basis within ten (10) days of receiving a completed
Service Documentation Report for services rendered in the prior month.

Notwithstanding the foregoing, Physician must submit the Service Documentation

Report each month in order to receive monthly compensation payments hereunder. If
Physician fails to deliver the Service Documentation Report in any month, then Group shall
not be entitled to receive compensation hereunder, and Hospital shall make no
compensation payments to Group until Physician delivers such Service Documentation
Report (and all other Service Documentation Reports then due) to Hospital. Upon delivery to
Hospital of all Service Documentation Reports then due, Group shall be entitled to receive,
and Hospital shall pay to Group, any monthly compensation payments that Hospital withheld
pursuant to the foregoing sentence.

18
 EXHIBIT B
PHYSICIAN SERVICES

Physician shall:

A. Serve as Medical Director of Neurosurgical Trauma for the Neurosurgical

Trauma Section. Responsibilities of the Medical Director include:

1. Serving as the point person and communication liaison with the

Hospital for all issues related to the management of neurosurgical trauma, including
preparing memoranda, organizing meetings and relaying Group issues and suggestions.

2. Monitoring existing Neurosurgical Trauma Section policies and

procedures and preparing and recommending changes to such policies and procedures as
necessary for the efficient operation of the Neurosurgical Trauma Section.

3. Assisting Hospital ni the review of treatment protocols and clinical

pathways related to neurosurgical trauma.

4. Assisting Hospital in the development of regional trauma systems and

triage of neurosurgical trauma cases during high census time.

5. Assisting Hospital in verifying that physicians providing services to

Hospital pursuant to the Trauma Services Agreement attend Hospital meetings in satisfaction
of attendance requirements of the American College of Surgeons for Level 1 Trauma
Centers.

6. Attending or requiring a designee who is a neurosurgeon or a

physician’s assistant to attend Hospital’s weekly multidisciplinary trauma management
meeting (currently held on ...... mornings) to ensure appropriate continuity of patient care.

7. Assisting Hospital in allocating operating rooms for neurosurgical

trauma services, participating in day-to-day use of operating rooms utilized for Neurosurgical
Trauma, utilization review of neurosurgical trauma cases, reviewing appropriateness of
scheduling of neurosurgical trauma cases, assisting Hospital in triaging neurological cases
and utilizing regional trauma systems during high census times.

8. Assisting Hospital in recruiting and retaining qualified staff for

Hospital’s operating rooms used for Trauma Services, interviewing applicants for
employment, advising Hospital with respect to such applicants and attending recruiting
functions.

B. Documentation of Time. Each month, Physician shall provide a Service

Documentation Report in the form attached hereto as Attachment B-1 documenting the
approximate time Physician devoted to the provision of service hereunder to the
Administrative Director of Trauma Services or such other Hospital administrator as the
President of the Hospital shall designate.

19
 ATTACHMENT B-1
FORM OF SERVICE DOCUMENTATION REPORT

MEDICAL DIRECTOR
SERVICE DOCUMENTATION REPORT

DATE: ________________ to _______________________

NAME: __________________________________________ , M.D.
DEPARTMENT: _________________________________________

DESCRIPTION OF SERVICES TOTAL HOURS

FOR PERIOD
1. Monitoring and reviewing Neurosurgical Trauma Section policies and procedures. Specifically:

2. Assisting in review of treatment protocols and clinical pathways. Specifically:

3. Assisting Hospital in the development of regional trauma systems and triage of neurosurgical trauma
cases during high census times. Specifically:

4. Assisting Hospital in verifying that physicians providing services to Hospital pursuant to the Trauma
Services Agreement attend Hospital meetings in satisfaction of the requirements of the American
College of Surgeons for Level 1 Trauma Centers. Specifically:

5. Attending or requiring a designee who is a neurosurgeon to attend Hospital’s weekly multidisciplinary

trauma management meeting to ensure appropriate continuity of patient care. Specifically:

6. Assisting Hospital in allocating operating rooms for neurosurgical trauma services, participating in
utilization review of neurosurgical trauma cases, reviewing appropriateness of scheduling of
neurosurgical trauma cases, assisting Hospital in triaging neurosurgical cases and utilizing regional
trauma systems during high census times. Specifically:

7. Assisting Hospital in recruiting and retaining qualified staff for Hospital’s operating rooms used for
Trauma Services, interviewing applicants for employment, advising Hospital with respect to such
applicants and attending recruiting functions. Specifically:

I CERTIFY THAT THE ABOVE NUMBER OF HOURS IS AN ACCURATE REFLECTION OF

THE TIME SPENT ON MY MEDICAL DIRECTOR DUTIES.
Signature: _____________________________________

________________________________________, M.D.

20
ABSCESS- Intracranial (cerebellar) 324.0 Craniotomy for repair 62100
Burr hole 61150 Lumbar drain 62272
Crani/supratent 61320
Crani/supratent 61514 Dislocation, occipitoatlantal 839.01
Crani/infratent 61522
Scalp 682.8 Echoencephalography 76506
Spinal, epidural 324.1
Lungs 513.0 Edema, cerebral 348.5
Unspecified 324.9 Cranial decomp 61340
Cervical 63265 Skull/abdominal 29026
Thoracic 63266
Empyema, brain 324.0
Arterial catherization (A-Line) 36620
Fluoroscopy (1 hour) 76000
Brachial Plexus Palsy 353.0 (1+ hour) 76001
Injury 953.4
FRACTURES
Cardiac Arrest 427.5 Skull, closed 800.1+
CPR 92950 Skull, depres, open 800.6+
Elevation/simple 62000
Catheter, central venous 36489 GSW, repair 62010
Pulmonary - Swan Ganz 93503 Base of skull/sinus 801.++
Supratent/evac hema 61312
Causalgia, upper limb 354.4 Crani/extradural/elevation 61582
Elev/compo/extradural 62005
Central Venous Catheter 36489 Crani/repair dura/elevation 62010
Sinus/obliterative/ablation 31081
Cerebral edema 348.5 Obliterative, w/flap/coronal 31085

Cerebral laceration/contusion 851.++ Cervical, closed 805.0+

Twist drill catheter 61107 Corpectomy/single 63081
Crani intracerebral 61313 Arthro/ant 22554
Arthro/post C1-2 22595
Closed Head Injury 854.0+ Arthro/posterlat/below C2 22600
Post-concussion syndrome 310.2 Additional segment 22614
w/open intracranial wound 854.1+ Wiring 22841
Twist hole for cath/Ventric 61107 Anterior Instr 22845
Crani w/penet brain wound 61571 “ ” 4-7 segments 22846
Post inst/segmental 22842
Compression— Brain 348.4
Nerve Root 724.9 Lumbar, closed, no cord inj 805.4+
Spinal Cord 336.9 Lumbar, closed, cord inj 806.4
Elevation DSF, simple 63200 Lumbar, open 805.5
Lumbar, open, cord inj 806.5
Concussion 850.+ Allograft/morselized 20930
Allograft/structural 20931
Contusion 851.++ Graft/morselized 20937
Craniotomy for ICH 61313 Autograft 20938
w/ tx of penetra wound 61571 Arthrodesis/anterior 22554
Arthrodesis/thoracic 22556
CPR 92950 Arthrodesis 22590
Arthro/lumbar/post 22612
CSF Leak 349.81 Post arthro/single 22630
FRACTURES (cntd) GSW to the head, vault 800.6+
Pedicle screws 22840 Skull base 801.6+
Wiring/instr/post 22841 Complicated open 851.3+
Post instr 3-6 seg. 22842 SDH 852.+
Ant instr 22845 General complicated 873.9
Lamin w/decomp 63001 Intracran/major vasc 900.89
Lumbar lamin 63005 Assault by firearm, purposely inf E965.4
Laminectomy 63015 Unspecified firearm/ accident?? E985.4
Anterior diskect 63075 Self-Inflicted E955.4
Additional segment 63082 Repair 7.6-12.5cm 12034
Vert/corpect/thor/single 63085 Subdural, craniotomy 61312
Additional segment 63086 Crani/extradural/subdural 61314
Crani w/penetrating wound 61571
Odontoid fracture 805.02 Elevat/comp/extradural 62005
Halo (apply/remove) 20661 w/repair dura/debride brain 62010
Open reduction 22318 Echoencephalography 76506
w/ grafting 22319
Reduct/posterior 22326 Head, deformity, acquired 738.10
Arthrodesis 22595 Crani for defect- 5cm 62140
Post/nonseg/instrum 22840 Replace bone flap 62143
(Harrington Rod) (usually requires -58 modifier)
Application of screw/cage 22851
wiring/bone dowel Head injury, unspecified 959.01
Screw fixation 22899
No screw 22548 HEMATOMA, epidural, fx 800.2+
Contusion 851.++
Thoracic fracture, closed 805.2 Intracranial (inj) 853.0+
Thoracic, open 805.3 Epidural 852.4+
w/cord inj 806.4 Subdural (injury) 852.2+
Reduction 22327 Complication from surg 998.1+
Bone graft/major 20902 Sinus/oblit/coronal inc 31085
Allograft/morselized 20930 Burr hole/ventric punct 61105
Allograft/structural 20931 Twist drill evac 61108
Wiring 22840 “ ” + another surgery 61130
Autograft/structural 20938 Burr hole, chronic/extra/subdural 61154
Ant arthro/below C2 22554 Crani/suprat/extral/subdural 61312
Arthro/post/below C2 22600 Crani/intracerebral 61313
Arthro/thoracic 22610 Elevat/simple/extradural 62000
Arthro/anterior 22808 Elevat/comp/extradural 62005
Lateral plating/post 22840 “ + repair dura/debri brain 62010
Post instr 3-6 seg 22842
Ant instr 2-3 segments 22845 Spinal (cord inj) 336.9
Appl prosthetic device22851 Thoracic excision 63271
Lamin, thoracic 63003 Spinal punct for drainage CSF 62272
Vertebral corpect 63081
Each add seg 60382 Hemorrhage, p injury 852.0+
Verteb corp/thorocolum 63087 “ traumatic 853.04
Corpectomy/lower/single 63090 Crani, suprat, extra/subdural 61312
Crani, intracerebral 61313
Posterior fossa 61315
Echoencephalography 76506
Hydrocephalus, comm 331.3 Paraparesis 344.9
Acquired, obstructive 331.4 Repair of dural/CSF leak 63707
w/ spina bifida 741.0+
Congenital 742.3 Paresthesias 782.0
Burr hole 61107
Endoscopic/third ventricle 62200 Post concussion syndrome 310.2
VPS 62223
Spinal 63740 Postoperative infection 998.5
I&D 10180
Hygroma p/trauma 852.26
Nontraumatic 432.1 Quadriplegia 344.0+

Incision & Drainage, simple 20000 Radiculopathy, cervical 722.0

Complicated 10061 Lumbar/thoracic 724.4
Cerv w/ decompression 63020
Increased intracranial pressure 348.2 ” one space, lumbar 63030
ICP monitor/ventric 61105 Ray cages 22630
Burr hole/ventric 61210 Autograft 20936
Lumbar lam 63047
Infection, local, unspecified 686.9 Ant diskectomy 63075
Cranial/bone 730.9
Spine 730.08 Reflex sympathetic dystrophy 337.20
Debrid skin/subcut tiss/muscle 11043
Craniotomy 61501 Respiratory failure 518.81
Chronic 518.83
Hardware complication 996.4 Tracheostomy 31600
Removal 22852
Scalp laceration 873.0
Injury, face/neck/scalp, superficial 910.+ Layer closure 7.6-12.5 cm 12034
Infected 910.9 Crani w/ exc & tx penet wound brain
Cranial nerves 951.+ 61571

Intracranial injuries 850-854 Sciatica 724.3

Implant catheter/ICP 61107 w/ radiculopathy 724.2

Laceration, scalp 873.0 Seizure, grand mal 345.3

Repair (20-30 cm) 12036 Petit 345.2
Convulsion 780.3
Ligamentous injury 839.01
Seroma 998.13
Microscope 69990 Wound revision 12035

MVA E812.++ Shunt malfunction 996.2

w/ infection 996.63
Neck Injury 959.0 Creation of shunt 62223
Revision 62230
Otorrhea, spinal 388.61 Removal 62256
Remove/replace 62258
Paralysis/Paraparesis 344.9
Sinusotomy, frontal/obliterative 31085
Paraplegia 344.1
Skull defect, acquired 738.10 Unlisted Procedure/Service
Cranioplasty 62140 Spine 22899
Skull base repair 62143 Arthros 29909
Sinus 31299
Spondylolisthesis (acq), lumbar 738.4
Lumbosacral (cong) 756.12 Ventriculitis 322.9
Allograft 20930 Ventricul/twist drill 61107
Morselized/harvest 20937 After craniotomy 61020
Posterior arthro 1 level 22612 Burr hole/fiberoptic dev 61210
Each add level 22614 Ommaya Reservoir 61215
PLIF 22630 Third Ventricle 62200
Post nonseg instru 22840 (no -51 modifier)
Post segment instrum 22842
Lumbar laminectomy 63012 Whiplash, neck 847.0

Spondylolysis: acquired 738.4 Wound infection 998.3

Cervical 756.19 Postop 998.5+
Lumbosacral 756.11 Incision & drainage 10180

Spondylosis, acquired 738.4 Critical Care

Cervical 721.1 or 756.19 99232/99233 < 30 minutes
w/o myelopathy 721.0 99291 First 30-74 minutes
Arthro/ant/cerv 22554 99292 Each additional 30 minutes
Cervical lam, 1-2 levels 63001
Cervical lam, 2+ levels 63015 Modifiers:
Ant disk, cerv 63075 GC= Supervision of residents
Hemilam w/decomp,1 lev 63020 22= Unusual services/greater than usual
Lumbar w/ myelopathy 721.42 (see 60)
Lumbar w/o myelopathy 721.3 25= E&M on day of surgery (see 57)
Autograft, inc. harvest 20938 32= Mandated Service
Each add space, cerv/lum 63035 50= Bilateral
51= Multiple procedures
Sprain/strain, cervical 847.0 57= E&M on day of surgery (see 25)
Back 847.9 58= Staged procedure during postop
Coccyx 847.4 period
Lumbar 847.2 59= Same Day, different surgery or
Sacrum 847.3 site/injury/lesion
Thoracic 847.1 60= Altered surgical field
anatomy/infection/trauma
Subclavian line 36489 62= Two surgeons (co-surgeons)
66= More than one surgeon using the same
Subluxation, cervical, closed 839.0+ code (surgical team)
76= Repeat procedure, same surgeon
Syringomyelia 336.0 78= Second surgery, related to 1st surg,
Crani, subocc, cord dec 61343 during postop period
79= Surgery (within 90 days) unrelated to
Tracheostomy 31600 previous surgery
80= Assistant surgeon
Ulnar nerve injury 955.2
Neurorrhaphy w/o transpos 64857
AANS Coding Hotline (800) 973-9298
Ultrasound 76986 (There is a fee for this service.)