January 2011 Labor Epidural Interpretive Guideline Revisions: Is Physician Supervision Required or NOT?
By: Bellinger P. Moody, RHIA, CPC, CPC-I, CCP
Executive Vice President of Compliance

February 21, 2011

As stated in a previous Medac Billing & Compliance Alert (sent February 2, 2011) from Medac Corporate Compliance Counsel, Christine Locay, CMS has removed language specifically exempting labor epidurals from the physician supervision requirements. Hospitals are now required to “establish policies and procedures, based on nationally recognized guidelines that address whether specific clinical situations involved anesthesia versus analgesia,” as well as, “the minimum qualifications and supervision requirements for each category of practitioner who is permitted to provide analgesia services.”

So what does this mean? Is physician supervision now required as it previously was before the change in May 2010? The answer to this question is up to your hospital! The revised Interpretive Guidelines allow each hospital to determine whether Labor & Delivery is analgesia versus anesthesia.

Under the most recent revision of the Interpretive Guidelines (January 2011), as so eloquently stated by prominent Healthcare Compliance Attorney David Vaughn in his recent Reading Room Article entitled “Interpretive Guidelines Revised Yet Again”,  dated 2/8/11:

“ It is critical to understand that if a particular sedation is characterized as “anesthesia,” and if a CRNA is involved in providing that anesthesia, then an anesthesiologist must be physically in the area to supervise that CRNA, and cannot be involved at the same time in supervising other CRNA’s who are not in the L&D suite. On the other hand, if the particular sedation is characterized as “analgesia,” then the CRNA does not have to be supervised, and the anesthesiologist does not have to be in the immediate area. Why? Because the federal regulation requiring MD supervision of CRNA’s, 42 CFR 482.52(a)(4), only applies to the administration of “anesthesia,” not analgesia. The January 2011 IG revisions acknowledge this, wherein CMS states, “Consequently, each hospital that provides anesthesia services must establish policies and procedures . . . that address whether specific clinical situations involve anesthesia versus analgesia.” (Article from Vaughn & Associates, LLC, Reading Room, 2/8/2011, “Interpretive Guidelines Revised Yet Again”)

These newly revised (January 2011) Interpretive Guidelines now allow each hospital to determine whether Labor & Delivery services are analgesia versus anestheisia. So, if you work with CRNAs and don’t want to have to hire additional anesthesiologists – that will be solely confined to the Labor & Delivery Suite – you should begin lobbying immediately with your hospital administration for a hospital policy that defines labor epidurals as analgesia,  and you will not have to satisfy the supervision requirement.

However, if your hospital defines labor epidurals as “anesthesia,” then CRNA supervision is required. Additionally, if your hospital defines your labor epidurals as “anesthesia”, CRNA supervision will be required regardless of whether you perform services in a non-medically directed practice (QZ), and regardless of the fact that the labor epidural cases aren’t Medicare. Remember, these are not billing rules. These are hospital conditions of participation (CoP’s) rules, and the hospital must apply the CRNA supervision rules to all cases –if it wants to continue participating with Medicare.

If you are in an opt-out state, you do not have to be concerned about this because your state has opted out of any CRNA Supervision requirements. However, if you are NOT in an opt-out state, you should immediately begin lobbying your hospital administration to define labor epidurals as “ANALGESIA”– that is, if you don’t want to incur the hassles and additional expenses that come along with the supervision requirement as a result of defining the Labor Epidural services as “ANESTHESIA”.

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.