Revision to Interpretive Guidelines for Anesthesia
By: Christine M. Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

Februrary 2, 2011

In late 2009, the Centers for Medicare & Medicaid Services (CMS) revised its Medicare hospital conditions of participation (COPs) interpretative guidelines for anesthesia services.  The guidelines specifically exempted labor epidural analgesia from the physician supervision requirement; thus, CRNAs, even in states that had not opted-out from the Medicare supervision requirement, could administer analgesia via epidurals/spinals without physician supervision.

Shortly after issuance of the 2009 guidelines, the ASA began voicing its concerns to CMS.  The ASA argued for removal of the labor exemption citing a variety of reasons including “compromise of safety net for mother and baby” and “non-reliable distinction between the effect of analgesic doses of epidural drugs and anesthetic doses on the sympathetic nervous system and its cardiovascular effects.”
In a 2011 Transmittal, CMS removed the exemption from physician supervision for labor epidural analgesia.  The conditions of participation now require hospitals to adopt policies and procedures governing analgesia that are based on national standards.  In addition, hospitals must establish minimum qualifications and supervision requirements for any provider administering analgesia and the qualifications of providers administering analgesia.

CMS also revised several anesthesia guidelines for pre- and post-anesthesia exams.  Regarding pre-anesthesia exams, the following elements of the exam must be performed within 48 hours of the surgery or procedure requiring anesthesia:

• Review of the medical history, including anesthesia, drug and allergy history; and
• Interview, if possible given the patient’s condition, and examination of the patient.

Other elements of the pre-anesthesia exam may be performed within 30 days prior to the surgery or procedure so long as they are reviewed and updated as necessary within 48 hours.  These elements include:

• Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk);
• Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access);
• Additional pre-anesthesia data or information, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation);
• Development of the plan for the patient’s anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient’s representative) of the risks and benefits of the delivery of anesthesia.

As to post-anesthesia exams, CMS has clarified that:

1) Post-anesthesia exams for same day surgery patients may be performed after discharge (if permitted by hospital policy) but must be completed within 48 hours of surgery;

2) Providers should perform and document a post-anesthesia exam within 48 hours for patients unable to participate in the exam and specify the reason for the patient’s inability to participate; and

3) “For patients who require long-acting regional anesthesia to ensure optimum medical care of the patient, whose acute effects will last beyond the 48-hour timeframe, a postanesthesia evaluation must still be completed and documented within 48 hours. However, there should be a notation that the patient is otherwise able to participate in the evaluation, but full recovery from regional anesthesia has not occurred and is not expected within the stipulated timeframe for the completion of the evaluation.”

The entire revised interpretative guidelines are available on the ASA’s website at the link below:

http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Regulatory-Victory-Pre-and-Post-Anesthesia-Interpretive-Guidelines.aspx

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information 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.