May 10, 2010

Many anesthesiologists are uncertain how the Revised Anesthesia Services Interpretive Guidelines issued by the Centers for Medicare and Medicaid Services (CMS) in December 2009 changed documentation requirements.

In most hospitals, the new Interpretive Guidelines do not require anything that the anesthesiology department is not already documenting pre- and intra-operatively. Typical forms used in the post-anesthesia care unit (PACU), however, do not necessarily contain every element mandated by the Guidelines, and may not be completed exactly as CMS now requires. That is why we start with the revised post-anesthesia evaluation rules.

Post-anesthesia evaluation

First, the evaluation must be:

  1. Completed and documented within 48 hours from the time the patient is moved into the “designated recovery area,”
  2. for any surgery involving general, regional or monitored anesthesia services
  3. in both the inpatient and hospital outpatient settings.
    1. Except for official Critical Access hospitals
    2. and except for ambulatory surgical centers (ASCs).
  4. Performed and documented by a practitioner who is qualified to administer anesthesia consistent with hospital policies as well as state licensure, i.e.,
    1. Anesthesiologist
    2. Other physician
      1. This includes residents and fellows, who are licensed physicians
    3. Dentist, oral surgeon or podiatrist if allowed to administer anesthesia under state law
    4. CRNA or AA.
      1. Nurses other than CRNAs are not qualified to complete or document the evaluation. This task cannot be delegated to practitioners other than those listed, even if supervised.
      2. Note that although CRNAs may perform and document the postoperative visit for purposes of the Interpretive Guidelines, this standard has no bearing at all on the rules for payment for medical direction services. In order to bill for medical direction, the anesthesiologist is still required to “provide indicated post-anesthesia care.”

The minimum elements of a post-anesthesia evaluation, that “must be clearly documented and conform to current standards of anesthesia care," are the following:

  1. Respiratory function, including respiratory rate, airway patency, and oxygen saturation;
  2. Cardiovascular function, including pulse rate and blood pressure;
  3. Mental status;
  4. Temperature;
  5. Pain;
  6. Nausea and vomiting; and
  7. Postoperative hydration.

If your anesthesia record, paper or electronic, does not include a checklist with space to enter information on the seven elements, plus an eighth line or text box for “Other,” you may want to consider revising or adding to the form you are using.

The revised Interpretive Guidelines are also more prescriptive about the timing of the post-anesthesia evaluation. This may still be completed in the PACU – but the patient has to be sufficiently aware in order to answer questions or perform simple tasks. It is worth quoting CMS’ expectations in full:

Accepted standards of anesthesia care indicate that the evaluation may not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc. The evaluation can occur in the PACU/ICU or other designated recovery location. For outpatients, the post-anesthesia evaluation must be completed prior to the patient’s discharge.

The American Society of Anesthesiologists objected to requiring completion of documentation prior to discharge of outpatients, but CMS rejected ASA’s efficiency and safety arguments. ASA also raised concerns about the revised Guideline’s failure to understand fast-tracking, which allows some patients to be able to perform tasks immediately, before being taken to PACU, to which CMS responded:

Finally, as indicated in the guidelines, the post-anesthesia evaluation generally would not be performed immediately at the point of movement from the operative suite to the designated recovery area. The guidance does not assert that it has to be completed and documented in a specific location; rather, it may be appropriate to perform the post-anesthesia evaluation in an alternative location as long as the patient has sufficiently recovered from the effects of anesthesia to participate in the evaluation to the extent necessary to assess the elements that must be included in the port-anesthesia evaluation. CMS recognizes that there is significant variation in the response of patients to different types of anesthetics and would expect hospitals to develop and follow policies and procedures that reflect these variations.

The paragraph quoted above gives anesthesiologists some flexibility. It is important to pay attention to the timing and documentation requirements because several of them may not be reflected in current practice.

Pre-anesthesia evaluation

The revised Interpretive Guidelines require that the pre-anesthesia evaluation be performed, completed and documented within 48 hours before administration of the first dose of anesthesia. In its letter to ASA, CMS clarified that the pre-operative examination, consultation and review of records only needs to be completed within the 48-hour window – the process of obtaining the information may start earlier.

In the interest of completeness, we reproduce here the list of minimum pre-anesthesia elements to be evaluated and documented:

  1. Review of the medical history, including anesthesia, drug and allergy history;
  2. Interview and examination of the patient;
  3. Notation of anesthesia risk according to established standards of practice (e.g. ASA classification of risk);
  4. Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access);
  5. Additional pre-anesthesia evaluation, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation);
  6. Development of the plan for the patient’s anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient’s representative) of the risks and benefits of the delivery of anesthesia.

Note that here, too, although the Interpretive Guidelines allow nonphysician personnel to conduct and document the pre-anesthesia evaluation, they do not replace or override the medical direction requirements. In order to bill for medically directing a CRNA or AA, the anesthesiologist is still required to perform the pre-anesthetic evaluation and examination as well as the other steps of Medical Direction. The Interpretive Guidelines describe the way in which hospitals must organize their anesthesiology departments and services. Payment for professional services is governed by the regulations on the Fee Schedule. See the last section of this Alert for more information on the difference betweent the hospital and the physician-payment requirements.

Intra-anesthesia evaluation

Although neither ASA nor anyone else of whom we are aware has suggested that the documentation requirements for the intra-operative portion of an anesthesia service might be overkill, and thus it is likely that every reader is already in compliance, we list the intra-anesthesia elements below, again for the sake of completeness and possibly training:

  1. Name and hospital identification number of the patient;
  2. Name(s) of practitioner who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner;
  3. Name, dosage, route and time of administration of drugs and anesthesia agents;
  4. Techniques(s) used and patient position(s), including the insertion/use of any intravascular or airway devices;
  5. Name and amounts of IV fluids, including blood or blood products if applicable;
  6. Timed-based documentation of vital signs as well as oxygenation and ventilation parameters;
  7. Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient’s response to treatment.

“Interpretive Guidelines” – So What?

The 18-page paper with all the new documentation requirements – and with other more startling changes to established principles – does not have anything to do with billing for your professional services, as you know by now. The Medicare Fee Schedule and all of its regulations come under the “Part B” program.

Hospital payment, on the other hand, depends on compliance with the Medicare hospital “Conditions of Participation” (CoPs) under “Part A.” The CoPs are spelled out in a large set of formal federal regulations, with topics such as “Medical Staff” and “Pharmacy Services” in addition to “Anesthesiology Services.”

Enforcement of compliance with the CoPs is done largely through surveys. The Joint Commission has “deemed authority” to verify compliance and uses individual surveyors to accomplish this function; state agencies may also send out hospital surveyors. The Joint Commission may impose standards higher than Medicare’s.

The Interpretive Guidelines are contained in Appendix A to the CMS State Operations Manual and they are the sometimes-explicit instructions to hospital surveyors. A Joint Commission surveyor will check whether your documentation shows, for example, that the post-anesthesia evaluation was performed within 48 hours. That is why your hospital may have contacted you about the documentation discussed in this Alert. Helping the hospital satisfy its Conditions of Participation, by satisfying the surveyors, is fundamental to maintaining a good relationship with the hospital, and we all know how important that is.

The Revised Interpretive Guidelines are available on ASA’s letter to CMS, ASA’s one-page analysis of the Guidelines, and CMS’ response to ASA are all available under “Practice Management” on the ASA web site,

Although we would like to temper the uncertainty about the new documentation requirements, we have just learned that ASA is in active discussions with CMS regarding possible further changes to the Guidelines. We can be “cautiously optimistic” that some of the problems, particularly with respect to post-anesthesia are, will be resolved. A correction is not certain, however, and if it happens, it probably will not become effective until the end of the summer at the earliest. Meanwhile, the Interpretive Guidelines as discussed in this Alert remain in force. As a practical matter, we would suggest modifying your existing forms only by adding attached notes until we find out that the Interpretive Guidelines are truly final.

With best wishes,

Tony Mira
President and CEO