December 21, 2009

The new Medicare payment rules for teaching anesthesiologists and for teaching CRNAs will go into effect in less than two weeks, on January 1, 2010. Initial written guidance from CMS on the reporting of time by teaching CRNAs was highly confusing – contradictory, in fact. We contacted CMS and found out how CRNAs are to report their time while supervising students in two concurrent cases. We also learned that the Agency planned to issue a correction, which it did late last week.

To recap previous Alerts, anesthesiologists will be able to receive full payment for each of two concurrent cases in which they are supervising residents for the first time since 1994. The Special Payment Rule for Teaching Anesthesiologists in the Medicare Improvements for Providers and Patients Act of 2008 (MIPPA) forced an end to the CMS policy of limiting each concurrent case to 50 percent of the allowable. Effective January 1, 2010, the services of a teaching anesthesiologist who is overseeing not more than two concurrent resident cases will be payable at 100 percent each, as long as

(A) The teaching anesthesiologist is present during all critical or key portions of the anesthesia service or procedure involved; and
(B) The teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) is immediately available to furnish anesthesia services during the entire procedure.

MIPPA also paved the way for a change in the amount that Medicare pays teaching CRNAs for supervising student nurse anesthetists (SRNAs) in concurrent cases. Section 139 of the Act requires the Secretary of Health and Human Services to “make appropriate adjustments . . . consistent with the adjustments made by the special rule for teaching anesthesiologists.” It also provides that the new teaching CRNA policy should maintain “the existing payment differences between teaching anesthesiologists and teaching certified registered nurse anesthetists.”

To implement these statutory changes, CMS published proposed regulations in the Federal Register on July 13, 2009; received and reviewed numerous “comments” from interested parties, and published final regulations in November. The implementation instructions sent to the Medicare contractors (Transmittal 1859 / Change Request 6706, November 20, 2009) differed materially from the inaccurate Medicare Learning Network (MLN) article published for providers with respect to the time reportable by teaching CRNAs.

The regulations and Change Request 6706 state correctly that beginning on January 1st, CRNAs will be able to report the total time for each of two concurrent SRNA cases:

To bill anesthesia time for each case, instruct the teaching CRNA that he/she must continue to devote his/her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient’s health status and other factors.

Until January 1st, the old policy on the anesthesia time to be reported by a CRNA supervising two SRNA cases still applies. Under that policy, the CRNA only reports actual face-to-face time with the SRNA in each case. To illustrate:

The teaching CRNA bills full base units if he or she is present with the student nurse anesthetist during the pre and post anesthesia care for each of the two cases. This policy is unchanged.

The MLN article (MLN Matters® Number: MM6706, November 20, 2009)- provided that the teaching CRNA should bill only “the time for each [of the two cases] based on the actual amount of time present with the student nurse anesthetist,” i.e., face-to-face time. Many interested parties saw the MLN article and assumed that there had been no change in teaching CRNAs' reportable time.

Due to the potential compliance implications arising out of the contradictory MLN Matters article, ABC sought clarification directly from CMS. We are pleased to report that our Director of Compliance, Hal Nelson, spoke with CMS official Jim Menas who clarified that the statement requiring face-to-face time in the MLN Matters article was made in error. Mr. Menas confirmed that the teaching CRNA may bill 100 percent of both full base and time (as opposed to face-to-face time only) in each of the two concurrent student cases as long as: (1) the teaching CRNA devotes his/her full time to the cases and is not involved in other services; and (2) the teaching CRNA must be present with each student nurse anesthetist during the pre and post anesthesia care. Mr. Menas also advised us that CMS would publish a revised version of the MLN article in the near future. CMS did so last week. The corrected version can be downloaded at:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6706.pdf

Please also note that in the commentary published in the November 25, 2009 Federal Register along with the final regulations, CMS advised that the standards of the American Association of Nurse Anesthetists’ Council on Accreditation of Nurse Anesthesia Programs with regard to supervision of students must be met. In particular, for periods of concurrency for two student nurse anesthetist cases, another qualified anesthesia provider (CRNA or anesthesiologist) must be available to fulfill the requirements. One such requirement is to be available for the student to summon for clinical assistance should it be necessary.

There is a take-home message here for everyone, regardless of whether you are or you employ teaching nurse anesthetists. Don’t trust everything you read even if it has an official “Medicare” logo. The Medicare Learning Network papers are written by an outside contractor. They are of course checked by CMS staff before publication, but there are many, many Medicare rules and there are numerous opportunities to get small but significant details wrong. When in doubt, check the statute, the regulations and the Transmittals to the contractors.

We hope this update has been helpful to you as we approach the January 1, 2010 effective date of the new regulations. We also wish all of our readers a Merry Christmas and a very happy new year.

Sincerely,

Tony Mira
President and CEO

Erratum: In our December 14, 2009 Alert on reporting PQRI measures in 2010, the second measure In Anesthesia Care Cluster 2 was incorrectly reported as Measure #30. The two measures in this cluster are in fact Measure #193 and Measure #76.

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