October 19, 2020

In contradistinction to the British lyricist who ironically advised, “We don’t need no education,” the pursuit of learning is imperative for all.  In fact, it must be a life pursuit, enabling the individual to uncover new layers of meaning as the years go by.  But before we can master the material set before us, we must first submit to other masters—to those who have already plumbed the depths of their particular niche of knowledge.  In other words, it’s good to have a teacher. 

It’s also good to be a teacher—especially in the context of anesthesia.  We will provide support for that statement in this two-part series of articles; but, for now, our readers should know that there are certain rules that have been published by both societal and governmental authorities that directly affect the anesthesia teacher.  It is, therefore, critical that you have a thoroughgoing appreciation of your obligations within the clinical classroom.  Whether you are instructing residents or student anesthetists (SRNAs), this series of articles will hopefully provide you with a better understanding of the teaching guidelines.

The Two-Case Principle

Perhaps the most basic rule for the teaching provider in an anesthesia case to understand is that he or she must not be involved in more than two cases if either one of the cases involves a resident or SRNA.  The theory behind this is that cases involving learners require more attention from the supervising clinician than those involving anesthesia program graduates.  So, while an anesthesiologist can medically direct up to four CRNAs (or AAs) simultaneously, he or she can only run up to two concurrent rooms if one or both contain a resident or SRNA. 

The two-case principle is supported by the American Society of Anesthesiologists (ASA) and represents the policy laid out by the Centers for Medicare and Medicaid Services (CMS), as well.  A Medicare Learning Network (MLN) article from 2010 states as follows:

. . . payment may be made to a teaching anesthesiologist under the Medicare physician fee schedule, at the regular fee schedule level, if he or she is involved in the training of residents in a single anesthesia case, two concurrent cases, or in a single case that is concurrent to another case paid under the medical direction rules.

It would appear, then, that CMS contemplates that the teaching anesthesiologist will only be involved in a maximum of two concurrent cases.  Examples would be: (a) two resident cases, (b) one resident case and one CRNA case, (c) one resident case and one SRNA case, (d) one CRNA case and one SRNA case, or (e) two SRNA cases.  The same two-case rule applies to a teaching CRNA (when no physician is involved).  The MLN continues:

. . . a teaching CRNA (not under the medical direction of a physician) can also be paid under Medicare Part B when supervising two student nurse anesthetists.

So, in order to avoid any payment issues, anesthesia teachers will want to structure their case schedules so that they are not running more than two simultaneous cases.

A Resident by Any Other Name

Since significant numbers of teaching cases involve residents, this may be an opportune time to point out what a resident is.  This may seem obvious at first, but there have arisen questions over the years from our client base that suggest the answer is not so cut and dry, at least not to some of our readers. 

From time to time, we will be told that the group is not working with a resident, but rather a fellow.  The implication is that there is an assumption on the part of the group that these are two separate classes of learners, and therefore the rules that apply to the teaching of residents may not apply in cases that involve a fellow.  While there may be some distinction in the clinical or educational qualifications relative to these two designations, you should know that Medicare makes no such distinction for payment purposes.

In the Medicare Benefit Policy Manual, we read the following:

For Medicare purposes, the terms “interns” and “residents” include physicians participating in approved postgraduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital setting, e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools. Where a senior resident has a staff or faculty appointment or is designated, for example, a “fellow,” it does not change the resident’s status for the purposes of Medicare coverage and payment.

Based on this and similar language gleaned from other authoritative sources, we believe that an “anesthesia fellow” should be regarded as a resident, from a billing perspective, when the fellow is in a case to which his or her fellowship applies.  Just as “a rose by any other name would smell as sweet,” a resident by any other designation is still considered a resident and is therefore included in the Medicare teaching guidelines.

Proof is in the Payment

Any discussion of payment in connection with the teaching of residents or students must begin with the observation that you are not getting paid for the work of the resident or SRNA; rather, you are being paid for your supervision of these individuals.  With that understanding in mind, let us now turn to the unique payment scenarios afforded by Medicare in the anesthesia teaching environment.  We’ll begin with teaching anesthesiologists.

A little history may be helpful to fully appreciate the remarkable rule CMS currently has in place for reimbursing the teaching anesthesiologist.  Prior to 2004, where an anesthesiologist was involved in two to four cases and where one or more of those cases involved a resident, the resident cases were deemed medically directed—meaning the anesthesiologist received 50 percent of the allowable on such cases.  In 2004, Medicare issued regulatory changes that allowed teaching anesthesiologists involved in two simultaneous resident cases (and no other cases) to bill both cases at the personally performed rate.  That is, if a teaching anesthesiologist ran two rooms, each with a resident, the anesthesiologist would receive the full base units for each case, along with the time units reflecting the anesthesiologist’s personal presence, i.e., “face time,” spent in each case.  The billing staff would list the personal performance modifier (AA) on both cases, along with a GC modifier to indicate residents were involved. 

One may ask, why would the government deem both cases to be personally performed when that designation is typically meant to describe a provider who is involved in only a single case?  This is where our history lesson gets interesting.  Back in 2002, CMS began allowing a teaching CRNA to be involved in two simultaneous SRNA cases and to get paid at essentially the personally performed rate for each (base units, plus face time).  In other words, the CRNA would submit each case with the QZ modifier.  Anesthesiologists naturally wanted a similar allowance, hence the reason for the unusual rule change for teaching anesthesiologists discussed above.  

To continue our lesson (who ever said history was boring?), a new rule in 2010 further changed the billing dynamic for a teaching anesthesiologist running two resident rooms.  Unlike the 2004 rule that limited the anesthesiologist’s time unit calculation to the his or her personal attendance in each case, the 2010 rule contained no such language as to face time.  Instead, the rule, as currently constructed, allows both full base units and full time units to be billed for each case.  So, as time has moved on, the teaching anesthesiologist has gradually gained greater reimbursement when involved in two resident cases.

To Be Continued

We will have much more to say in our second installment of this topic in a couple of weeks; so, be on the lookout for that alert.  We will review specific case scenarios, documentation requirements and instructions that outline what an anesthesia teacher is allowed to do while supervising his or her cases.  For now, we want you to let us know if you have any questions or concerns about the teaching requirements.  You can reach out to your account manager or contact us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO