MEDAC BILLING & COMPLIANCE ALERT
November 9, 2009

New Teaching Rules for Anesthesiologists
By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

The 2010 Medicare Physician Fee Schedule Final Rule has new rules for teaching anesthesiologists in reference to residents and SRNA’s.  I will address both rules and the impact they may potentially have on your anesthesia practice.

SRNA’s

Currently, as you know, an anesthesiologist cannot medically direct greater than 2 cases where there are SRNA’s involved.  Well, one of the ways many anesthesia groups handled this was by “attaching them to the hip of a CRNA” – which allowed them to medically direct up to 4 rooms due to the fact that each room had a CRNA and an SRNA in it and groups took the position that this model allowed them to medically direct 4 cases, since they were medically directing the CRNA’s, and not the SRNA’s.  Well, starting in 2010, this will no longer be allowed.  In fact, the new rule for 2010 implies that you cannot medically direct greater than 2 cases with SRNA’s, even if the CRNA’s are involved in all 4 rooms the entire time. Effective for dates of service after January 1, 2010, if you want to have 4 rooms going, each of the SRNA cases must be billed as non-medically directed by the CRNA, and be billed as QZ in the name of the CRNA with only the time that the CRNA documents the he/she was in the room.

CMS has taken the position that if you are going to bill medical direction for SRNA’s, you can only medically direct a maximum of two cases, period.  If you try to medically direct greater than 2 cases, even if you only have 1 SRNA in 1 of the rooms, you cannot bill your portion for any of these cases because you will have exceeded the SRNA concurrency rule.  Instead CMS’s new rule provides that if you have 4 rooms ongoing, you can choose not to medically direct the SRNA rooms, and bill the services as non-medically directed in the name of the CRNA.  CMS asserts that the teaching rule is limited to situations where the CRNA is not medically directed, therefore, if you want to bill greater than 2 rooms involving SRNAs, you will have to adopt the non-medical direction model for these rooms, and bill in the name of the CRNA.

Subsequently, in order to bill these cases as non-medically directed (QZ) modifier, CMS says that the CRNA has to be with the SRNA during the pre and post anesthesia services included in the anesthesia base units.  Therefore, the pre-op evaluation and the post-anesthesia care note must be signed by the CRNA in these cases.  Additionally, CMS now requires that the CRNA be present during the entire case with the SRNA and consequently, the CRNA must document his/her time in the room separately from the SRNA’s time.

AA’s

With regard to Anesthesiologist Assistants (AA’s), CMS states that since they must work under the supervision of an anesthesiologist, the teaching rules do not apply to them.

Residents

On a more positive note, the 2010 Medicare Fee Schedule Final Rule does do away with  a previous rule in reference to medical direction of residents that will bode well for reimbursements for Anesthesiologists.  Currently, teaching anesthesiologists are only allowed to bill personally performed if they are 1:1 with a resident.  Under the new teaching rule (effective for dates of service on or after January 1, 2010) teaching anesthesiologists will be allowed to bill as personally performed if they are 1:1 or 1:2 with residents.  Additionally, anesthesiologists are not limited to the amount of time spent in each of the two cases, but rather, the entirety of  both cases can be billed. Remember though, that as the teaching physician you are required to document an affirmative not that you were “present for all critical events and immediately available throughout”.  In a recent “Reading Room” alert (November 6, 2009), Healthcare Attorney David Vaughn of Vaughn & Associates explains further:  

“Not only can the anesthesiologist bill for two resident cases at the same time, but also, the second case can either be another resident, billed as personally performed, or where the second case is medically directed with a CRNA, provided that the teaching anesthesiologist documents that he/she is present for all critical events and immediately available throughout the resident case, even though he has a second case which is being medically directed.  However, this only applies where the teaching anesthesiologist has 2 cases.  If the teaching anesthesiologist were to pick up a third concurrent case, all cases would have to be billed as medically directed.  The rule is obviously designed to allow a resident case to be billed as personally performed, as long as the anesthesiologist has no more than two cases, regardless of whether the 2nd case is a resident case or a CRNA case.  The teaching anesthesiologist must bill the AA and GC modifiers on the same 1500 form for the resident case(s).  All anesthesiologists in the group can participate as the teaching physician and there is no limitation on handoffs.  The old rule adopted in 2005 of split billing the time between the two cases is deleted.  Under the old rule, which has been the rule since 2005, anesthesiologists were paid bull base for both teaching cases, but the only time billable was the time spent personally with the resident, which mirrored the effect of the CRNA rule for teaching SRNA’s.”

These new CMS rules are going to require you to revisit your scheduling activities – especially those practices that don’t employ the CRNA’s but also utilize SRNA’s.  In practices with this model, CMS is saying that you can only have 2 rooms going with a SRNA, and you can no longer address this issue under the guise that you are medically directing 4 CRNAs.   Although you can bill these cases as non-medically directed (QZ) by allowing the CRNA to cover the cases without medical direction of an anesthesiologist, it still doesn’t provide any assistance for  those practices that don’t employ the CRNA’s.  These practice models are going to have to limit their involvement to two cases where there is a SRNA involved, or else, they cannot bill for the Anesthesiologist’s involvement in the those cases.  Even in the case where you group employs the CRNA’s and puts a CRNA in the room the entire time, you will have to be certain that the CRNA conducts and documents, with the SRNA, the pre-operative evaluation and the post-operative care note.  Otherwise, you will not be in compliance with the new teaching CRNA rule requirements.  I strongly recommend that you start analyzing your current staffing models to determine how these changes will impact your scheduling and staffing needs.  Getting an head start will help you to minimize or eliminate any potential losses as a result of these new teaching rules.  Keep in mind that these new rules are effective on or after January 1, 2010.

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.