MEDAC BILLING & COMPLIANCE ALERT
November 18, 2009

By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

Clarification & Update:  2010 SRNA Medical Direction Rule

On November 9, 2009 I issued a “Medac Billing & Compliance Alert” entitled “New Teaching Rules for Anesthesiologists”.  In this alert I addressed my interpretation of the 2010 Medicare Physician Fee Schedule Final rule as it pertains to rules for teaching anesthesiologists in reference to Residents and SRNAs. 

As you may or may not know, there has been a great deal of discussion (and alarm) about the “CORRECT” interpretation of the 2010 SRNA teaching rule.  Currently, the anesthesia administrative community is split in its interpretation of the 2010 SRNA teaching rule:

• Some assert that there is no evidence of a change (in the 2010 Final Rule)  to the medical direction rules pertaining to an Anesthesiologist medically directing up to four teaching CRNAs whose cases involve SRNAs.

• Others believe that the 2010 SRNA teaching rule implies  that an anesthesiologist cannot medically direct more than 2 cases with SRNAs, even if the CRNAs are involved in all 4 rooms the entire time.

Due to the “great divide” in the interpretation of the 2010 SRNA teaching rule, we consulted with external legal counsel  to obtain a “formal ASA opinion” on this issue stating that it is the ASA’s position that we can bill 1:4 when there are both CRNAs and SRNAs in the room.  Our external legal counsel set up a conference call with Mr. Harvey “Chip” Amoe III, JD MPA, Assistant Director, Federal Affairs, American Society of Anesthesiologists – to obtain a “formal ASA opinion”.  However, Mr. Amoe reserved immediate interpretation and thought it would be prudent to address the matter directly with CMS prior to issuing a “formal ASA opinion” on the matter.

Therefore, we are awaiting a response from Mr. Amoe on this issue at which time we will issue another alert to clarify the interpretation of the rule – once and for all.  Until then, our interpretation of what we viewed as the “implied” new SRNA teaching rule (in the November 6th Medac Billing & Compliance Alert entitled:  “New Teaching Rules for Anesthesiologists”) is UNOFFICIAL.  We will notify you immediately upon receipt of our response from external legal counsel via Mr. Amoe.

Basis For Medac Interpretation of 2010 SRNA Teaching Rule

Since there are differing opinions on the interpretation of the 2010 SRNA Teaching rule, I wanted to share and explain the basis of my interpretation. 

In my opinion, the issue is not whether there is a new regulation being adopted; I agree that the regulation on medically directing SRNAs has not changed.  That begs the question.  The issue is whether we have been interpreting the existing rule incorrectly all along.  I have read each Final rule issued over the past 15 years.  This is the first time I recall CMS giving an example of medical direction where there is both a CRNA and a SRNA in the room at the same time.  Yes, it is but an example, but it is the only time they have spoken on the issue, and the only example they give is 1:2 – and that example is squarely based on the 1:2 SRNA medical direction rule.  I agree that CMS does not come out and state that you cannot do 1:4; however, there are 2 competing rules here:  (1) medical direction of SRNAs which in the Code of Federal Regulations is limited to 1:2; and (2) medical direction of CRNAs which is expanded to 1:4.  Who is the MD medically directing?  The SRNA or the CRNA?  During the maturation process of a SRNA, many of my clients tell me that in the beginning, the SRNA is watching the CRNA and learning by watching.  In that instance, since the CRNA is performing the anesthesia, the anesthesiologist is medically directing the CRNA.  However, as time goes along, the SRNA begins to learn by doing, not watching.  At the latter stages of the SRNA’s education, the CRNA is watching the SRNA perform the anesthesia.  At that point, who is the MD medically directing?  The CRNA or, more likely, the SRNA?  If so, we are limited to 1:2, since the medical direction would be of the SRNA, not the CRNA.  So, my interpretation was predicated on  the premise that in reality, the issue before us is not whether there is a new rule being announced, but rather, whether CMS is taking the position that notwithstanding a CRNA being in the room, the MD is actually medically directing the SRNA.

Over the years, many anesthesia groups have taken the position that by placing a CRNA in the room with the SRNA the entire time, the medical direction rules of 1:4 will apply, under the assumption that the MD is medically directing the CRNA, not the SRNA.  I have always viewed this as a gray area, but it made economic sense to me and we have utilized that assumption.  However, with the new 2010 Rule, I am concerned that CMS is now aware – perhaps for the first time – that there are scenarios where the SRNA and a CRNA are both in the room at the same time and the case is being medically directed.  I am concerned that their absence of a discussion of 1:4 in that scenario is an indication of their thinking that because there is a SRNA involved, the medical direction is of the SRNA, not the CRNA, and thus, they are telegraphing their thoughts that this scenario is limited to 1:2. 

There you have it – the basis of my interpretation.  Frankly, I sincerely hope I am wrong, as this will wreak havoc on many SRNA teaching programs.  I will notify you as soon as we receive word from our legal counsel via Mr. Amoe after consulting with CMS.

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.