Is a Post-Op Pain Block Placement Allowed During Medical Direction?

By: Justin Vaugh, M.Div, CPC
Director of Compliance
4/14/2011

A recent article published by the ASA has created a stir among some anesthesiologists (MDAs) who have been working under the belief that they can place a postoperative pain epidural or nerve block while medically directing.  In the April  2011 edition of the ASA Newsletter (Volume 75, Volume 4), Dr. Jean-Louis Horn writes:

“The Medicare insurance program has strict rules about allowable activities during medical direction.  Placement of postoperative pain catheters is not one of the activities specifically allowable while medically directing.”

As you may know, CMS has published in its Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50C, a list of activities a medically directing MDA may perform without (a) jeopardizing the MDA’s medical direction status, or (b) adding an additional case to the MDA’s concurrency count.  For example, the list of allowed activities in the MCPM includes placing a labor epidural.  Such placement would NOT count as an additional medically directed case for that doctor.  While Dr. Horn is correct that CMS does not “specifically” include post-op pain procedures in its MCPM list of allowed tasks during medical direction, it would nevertheless be inaccurate to apply a blanket prohibition against performing such procedures while so directing.

The issue is not so much what allowed procedures are in the MCPM list, but whether the list, itself, is meant to be taken as exhaustive or illustrative.  The wording of this section of the MCPM has been interpreted by many Medicare state medical directors as allowing additional activities during medical direction, including the placement of post-op pain catheters.  I am only aware of three regional or state carrier medical directors who have taken the position that the MCPM list is exhaustive and therefore would exclude any activities other than those found in the MCPM list (even though two of these medical directors violated their own interpretation by authorizing an activity not found in the MCPM list!).  This narrow rendering runs counter to that of several state/jurisdictional carriers who have held that the MCPM list simply offers examples of the kinds of activities one may perform while medically directing. 

While there are divergent views among the carriers on this point, the primary precept one can take from this section of the MCPM is found in the following excerpt:

However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature.

Medicare carriers in several states have stated in official opinion letters submitted to our offices and those of healthcare attorneys that as long as the medically directing doctor adheres to the parameters found in the excerpt immediately above, it will be generally up to the clinical judgment of the MDA to determine whether a given activity ultimately undermines his/her medical direction status.  Other carrier medical directors have gone so far as to enumerate specific activities a medically directing MDA can perform in addition to those listed in the MCPM.  For example:

•    Medac has received information from the Medicare carriers/contractors in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Ohio, West Virginia, Pennsylvania, New Jersey, Delaware, Maryland, District of Columbia, Virginia, South Carolina, Georgia, Florida, Alabama, Texas, New Mexico, Arizona, Nevada, California, North Dakota, South Dakota, Utah, Wyoming, Montana, Oregon, Washington, Alaska and Hawaii that gives explicit permission to doctors to place an invasive line or post-op pain epidural/nerve block while medically directing.

•    Trailblazer, the Part B carrier for Texas, Oklahoma, New Mexico and Colorado, has recently stated that it would allow medically directing doctors to give bathroom or short lunch breaks to CRNAs during medical direction.  That is, the MDA could be one-on-one with the patient while the anesthetist is taking a short break.  Such a scenario would not affect that MDA’s medical direction status.

•    Other carriers, such as North Carolina, take a more narrow approach, but nevertheless allow the performance of a pre-op evaluation in connection with an upcoming case while medically directing other cases.

Having communicated with multiple state and regional Medicare carriers over the years, I can tell you that each jurisdiction has its own interpretive twist on the MCPM list of allowed activities.  However, based on responses from medical directors across the country to our inquiries on this issue, the great preponderance of Medicare jurisdictions have indicated the MCPM list is illustrative and therefore the medically directing doctor is not necessarily constrained by the specific examples presented therein.  

If you have further questions about this, or are not sure what the rule is in your state regarding allowed activities during medical direction, please inform your Medac compliance representative so that we can research this further on your behalf.

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.