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Posts Tagged ‘anesthesia’

Medically Directed Anesthesia – Payment Conditions

Monday, January 23rd, 2012

Conditions For Payment Of Medically Directed Anesthesia

 In my previous article regarding anesthesia billing practices, I neglected to mention another risk associated with overbilling for medically directed anesthesia.  Engaging in the described practices tends to raise issues beyond the “double billing” issue that is directly raised.  This type of issue can also raise further scrutiny of the source bills.  For example, an insurer may decide to perform an extended audit of billings as a result of the billing anomalies that I described in my previous article.  The review might disclose a systematic problem documenting all of the prerequisites that permit the billing for medically directed services.

            In order to bill medically directed anesthesia services, seven primary elements need to be clearly indicated in the medical record:

  1.  The physician must perform a pre-anesthetic examination and evaluation;
  2. The physician must prescribe the anesthesia care;
  3. The physician must personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence;
  4. The physician must assure that any procedures in the anesthesia plan, that he or she does not perform, are performed by a qualified individual as defined in the operating instructions;
  5. The physician must monitor the course of anesthesia administration at frequent intervals;
  6. The physician must remain physically present and available for immediate diagnosis and treatment of emergencies; and
  7. The physician must provide indicated post-anesthesia care.

If one or more of these elements is not indicated in the medical record, the claim may be denied altogether, sometimes for both the physician and the CRNA services.  The physician alone is responsible for documenting each of these activities in the chart.  Like everything else, if it is not in the chart, it did not take place.

You can see how the originally risky billing practice could trigger a further audit and in turn uncover deficiencies in documenting the conditions for medically directed reimbursement.  If a systematic error is made in documenting the seven elements, there can be significant additional financial exposure to the group.

Anesthesia Conditions of Participation – CMS Interpretive Guidelines

Tuesday, January 12th, 2010

 CMS Interpretive Guidelines – Anesthesia Conditions of Participation

On December 11, 2009 CMS released updated Interpretive Guidelines for the Anesthesia Services Condition of Participation (CoP) for Hospitals as an attachment to S&C memo 10-09. Among other things, this guidance was a response to requests for clarification of the distinction between analgesia and anesthesia, given that the regulation at 42 CFR 482.52(a) limits the administration of anesthesia to certain types of practitioners.

The guidance now specifies that hospitals must establish policies and procedures that address whether specific clinical situations involve anesthesia versus analgesia. In addition, hospitals must also specify the qualifications for each category of practitioner who administers analgesia and their supervision requirements. These policies must be based on nationally recognized guidelines. For those procedures that require the administration of anesthesia, the regulations at 42 CFR 482.52(a) concerning who may administer anesthesia continue to apply.  Hospitals that provide Anesthesia Services must also periodically evaluate the effects of their policies regarding the administration of analgesia and anesthesia on the safety of patients and adopt appropriate modifications to these policies as necessary.


With respect to the pre-anesthesia evaluation, the evaluation must be completed within 48 hours prior to surgery or a procedure requiring anesthesia services. However, some individual elements may be performed prior to that period, so long as they are reviewed and appropriately updated within the 48 hour timeframe.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

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