104 STAT. 1388-62 PUBLIC LAW 101-508—NOV. 5, 1990 designated under section 322(a)(1)(A) of the Public Health Service Act as a health manpower shortage area.". 42 USC 1395U. (2) CONFORMING AMENDMENTS. — Section 1842(b)(4)(F), as amended by subsection (a), is amended— (A) in clause (i), by striking "physicians' services and", (B) in clause (i), by striking "physician's or", and (C) in clause (ii)(II), by striking "physician or" each place it appears. 42 USC 1395W-4 (c) CONFORMING ADJUSTMENT IN CONVERSION FACTOR COMPUTA- note. TiON. — In computing the conversion factor under section 1848(d)(1)(B) for 1992, the Secretary of Health and Human Services shall determine the estimated aggregate amount of payments under part B for physicians' services in 1991 assuming that the amendments made by this section (notwithstanding subsection (d)) applied to all services furnished during such year. 42 USC 1395u (d) EFFECTIVE DATES. — note. (1) The amendments made by subsection (a) apply to services furnished after 1990, except that— (A) the provisions concerning the third and fourth years of practice apply only to physicians'services furnished after 1990 and 1991, respectively, and (B) the provisions concerning the second, third, and fourth years of practice apply only to services of a health care practitioner furnished after 1991, 1992, and 1993, respectively. (2) The amendments made by subsection (b) shall apply to services furnished after 1991. SEC. 4107. ASSISTANTS AT SURGERY. (a) PHYSICIANS AS ASSISTANTS-AT -SURGERY.— (1) IN GENERAL.— Section 1848(i) (42 U.S.C. 1395w-4(i)) is amended by adding at the end the following: " (2) ASSISTANTS-AT-SURGERY.— "(A) IN GENERAL.— Subject to subparagraph (B), in the case of a surgical service furnished by a physician, if pay- ment is made separately under this part for the services of a physician serving as an assistant-at-surgery, the fee schedule amount shall not exceed 16 percent of the fee schedule amount otherwise determined under this section for the global surgical service involved. "(B) DENIAL OF PAYMENT IN CERTAIN CASES. — If the Secretary determines, based on the most recent data available, that for a surgical procedure (or class of surgical procedures) the national average percentage of such procedure performed under this part which involve the use of a physician as an assistant at surgery is less than 5 percent, no payment may be made under this part for services of an assistant at surgery involved in the procedure.". 42 USC 1395W-4 (2) AppucATiON IN 1991.— Section 1848(i)(2) of the Social Secunoterity Act, as added by the amendment made by paragraph (1), shall apply to services furnished in 1991 in the same manner as it applies to services furnished after 1991. In applying the previous sentence, the prevailing charge shall be substituted for the fee schedule amount. (b) CONFORMING AMENDMENT. —Section 1862(a)(15) of such Act (42 U.S.C. 1395y(a)(15)) is amended— (1) by inserting "(A)" after "(15)",
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