July 27, 2009

In 1998, CMS specifically adopted a regulation to address medical documentation in connection with conditions for payment for medically directed anesthesia services. According to 42 CFR §415.110(b):

• The physician alone inclusively documents in the patient’s medical record that the conditions set forth in paragraph (a)(1) have been satisfied, specifically documenting that he or she performed the pre-anesthetic exam and evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence where applicable.

Fortunately or unfortunately, depending on your perspective, CMS has not provided specific instruction on exactly how this documentation must be accomplished. With many anesthesia practices having a renewed focus on compliance, we often get inquiries concerning this topic and how best to accomplish this documentation.

From a practical standpoint, there are multiple ways in which medical direction can be documented. The reality is that the key to effectuating meaningful compliance with documentation requirements in your practice is to carefully select a documentation method that will obtain physician buy-in and to make sure all necessary medical direction criteria are accounted for. Per 42 CFR §415.110, medical direction requires that for each patient the anesthesiologist fulfill the following seven (7) specific responsibilities:

• Performs the pre–anesthetic exam and evaluation
• Prescribes the anesthesia plan
• Participates in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence
• Ensures that any procedures in the plan that he/she does not perform are performed by a qualifying individual
• Monitors the course of anesthesia at frequent intervals
• Remains physically present and available for immediate diagnosis and treatment of emergencies
• Provides indicated post-anesthesia care

Absent instruction from your Medicare contractor directing a specific method, some potential documentation methods a practice may choose to consider include the following examples:

1. Individual Attestation Statements with Comment Section:

   Some practices use individual pre-printed or stamped attestation statements with corresponding signature and comment lines included on the operative anesthesia record similar to the following:

   Statements	Signature	Applicable comments
   • I participated in key portions:	_____________	_____________
   • I monitored at frequent intervals:	_____________	_____________
   • I remained immediately available:	_____________	_____________

   The comment line can be used to more fully document important information. For example, in a case involving general anesthesia, the anesthesiologist could specifically comment on presence for induction and emergence with regard to the attestation for participation in key portions (e.g., induction-smooth).

   Moreover, the anesthesiologist should personally document his/her performance of the pre-anesthesia exam and prescribing of the anesthesia plan on the pre-anesthesia record with corresponding signature. In addition, an attestation statement could be added to the pre-anesthesia record to account for these items such as:

   I performed the pre-anesthesia exam and prescribed the plan: _______________

   When indicated, the anesthesiologist must also document any post-anesthesia care on the post-anesthesia or other applicable record.

2. Combination of Attestation Statements and Time Line Initialing:

   Some practices have utilized a combination approach consisting of the use of attestation statements similar to those discussed above along with a policy requiring the anesthesiologist to initial the graphic time line at times when he/she enters the room. Some view this option as ideal as it highlights the anesthesiologists presence in the case for monitoring at frequent intervals and participation in key portions.

3. Handwritten Notations-No formal attestations:

   Some practices do not favor attestation statements and document medical direction by requiring the anesthesiologists to notate the comment section of the record or other applicable portions of the record to reflect the requirements of medical direction.

Please note that the above examples are not meant to be an exhaustive list of documentation methods available as there are other alternative documentation strategies or combinations that may be appropriate for your practice environment (e.g., some practices that do not typically hand-off cases may employ a more global attestation statement that could be signed by one anesthesiologist who provides all elements). There are pros and cons with regard to each documentation strategy. For example, some raise concerns that pre-printed attestations can lead to pre-marking prior to the actual rendering of the service or that the anesthesiologist will mistakenly forget to sign a particular statement leaving a glaring blank in the documentation. On the other hand, some favor attestation statements as they feel that physicians who document in the comments section (without documentation triggers offered by attestation statements) will fail to include all necessary documentation. Regardless of the documentation method that you employ, your documentation should: (1) accurately reflect the services rendered; (2) accurately reflect the appropriate provider who rendered the service; and (3) include all necessary elements to establish that the medical direction criteria have been established. We encourage all groups to periodically remind their physicians of the importance of careful documentation practices and to select a documentation method that will achieve the greatest level of compliance for the practice. 

As always, we welcome your feedback. If you have a question about this topic or if you have another topic you would like discussed, please let us know.

Finally, we have received a tremendous number of responses over the past couple of days to our postcard campaign. If you would like to participate please do so promptly. Our goal is 10,000 post cards with a unified message from the anesthesia community. I’m confident we will achieve that goal with your help.

With Best Wishes,
Tony Mira
President and CEO