Post-Anesthesia Assessment:
CMS Revises its Recent Rule

By: Justin Vaughn, M.Div, CPC
Director of Compliance

As many of you know, CMS released at the end of 2009 an advanced copy of “Interpretive Guidelines” (IGs) pertaining to rules for hospital surveyors, as found in Appendix A of the Medicare State Operations Manual.  Among other items, the IGs addressed time limitations for completing the post-anesthesia assessment.  Of some concern to many anesthesia providers was the stipulation that, for outpatient cases, the assessment would have to be completed before the patient was discharged from the facility.  That instruction has now been revised.  

According to the May 21, 2010 version of the IGs, the following sentence has been deleted:  

“For outpatients, the post-anesthesia evaluation must be completed prior to the patient’s discharge.”  

This means that outpatient cases will default to the same requirements as outlined for inpatient cases; that is, you will have 48 hours from the moment the patient is transported to the recovery area to complete the post-anesthesia assessment.  Naturally, you will need to begin the assessment long before this time period has elapsed, as the IGs also advise that the patient must participate in the applicable portions of the assessment (and thus must be sufficiently recovered to be able to answer questions, perform simple tasks, etc.).

In addition to your fellow anesthesia providers, you may want to bring this revision to the attention of appropriate hospital officials in the event facility policies and protocols are at issue.  Thank you, and have a great week!

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environments, the author's presentation of this information and any general advice previously published might become outdated.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.