Transcript Medical Direction

CMS Billing Compliance Requirements
For Anesthesiologists
In addition to the seven steps of medical
direction…You may not medically direct more
than 4 anesthesia locations at one time…
Changes coming
Spring of 2013
The anesthesiologist must:
1) Perform a pre-anesthetic examination and
evaluation
2) Prescribe the anesthesia plan
3) Participate in the most demanding aspects
of the anesthesia plan, including, if applicable,
induction and emergence
4) Ensure that any procedures in the anesthesia
plan are performed by a qualified individual
5) Monitor the course of anesthesia
administration at frequent intervals
6) Remain physically present and available for
immediate diagnosis and treatment of emergencies
7) Provide indicated post-anesthesia care
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Address an emergency of short duration in the
“immediate area” (see “immediately available”)
Administer an epidural or caudal anesthetic to relieve
labor pain
Perform periodic rather that continuous monitoring
of an obstetrical patient
Receive patients entering the operating suite for the
next surgery
Coordinate scheduling matters
Place invasive lines and regional blocks in the holding
area or PACU for pre- or post-surgical patients
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Must be done within 48 hours of surgery/
procedure
Must be documented
Must show evaluation and exam was done by an
anesthesiologist culminating in an ASA score
(Cleveland Clinic modification)
Evaluation must document patients condition
Documentation of exam findings must be
included. “Performed Exam” is not sufficient.
ASA PS
Category
Preoperative
Health Status
Comments, Examples
ASA PS 1
Normal healthy
patient
No organic, physiologic, or psychiatric disturbance;
excludes the very young and very old; healthy with good
exercise tolerance
Patients with
mild systemic
disease
No functional limitations; has a well-controlled disease
of one body system; controlled hypertension or
diabetes without systemic effects, cigarette smoking
without chronic obstructive pulmonary disease (COPD);
mild obesity, pregnancy
Patients with
severe systemic
disease
Some functional limitation; has a controlled disease of
more than one body system or one major system; no
immediate danger of death; controlled congestive heart
failure (CHF), stable angina, old heart attack, poorly
controlled hypertension, morbid obesity, chronic renal
failure; bronchospastic disease with intermittent
symptoms
ASA PS 2
ASA PS 3
ASA PS
Category
Preoperative Health
Status
Comments, Examples
ASA PS 4
Patients with severe
systemic disease that
is a constant threat to
life
Has at least one severe disease that is poorly
controlled or at end stage; possible risk of
death; unstable angina, symptomatic COPD,
symptomatic CHF, hepatorenal failure
ASA PS 5
Moribund patients who
are not expected to
survive without the
operation
Not expected to survive > 24 hours without
surgery; imminent risk of death; multiorgan
failure, sepsis syndrome with hemodynamic
instability, hypothermia, poorly controlled
coagulopathy
ASA PS 6
A declared brain-dead
patient whose organs
are being removed for
donor purposes
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The anesthesia plan must be prescribed by the
anesthesiologist based on the evaluation and
exam of the patient and the procedure being
performed
The anesthesiologist must include documentation
specifying GA, MAC or Regional. “Formulated
anesthesia plan” is not acceptable.
Copy of preoperative evaluation form must be
sent to billing office along with copy of
anesthesia record
Documentation, Documentation,
Documentation
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Definitions of: Induction and Emergence
(GA only)
CAA policy: Pre-signing presence for
induction and emergence is not acceptable
and is prohibited.
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Not specifically defined by CMS
Induction is defined as a continuum that begins
with the administration of medications until
“the establishment of a depth of anesthesia
adequate for surgery”.
CAA compliance policy states: For purposes of
documentation, induction will include the time
from the administration of IV agents or
initiation of inhalation agents, until the patient
is ready for surgical incision.
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Emergence is defined as a continuum that
begins as the anesthetic level is being reduced
until the patient is stable in the PACU.
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It is the responsibility of CAA and CAA’s
Medical Compliance Officer to ensure that
records are on file to document anesthesia
providers’ qualifications.
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CMS has not specifically defined “frequent
intervals”
CAA’s definition, based on literature review and
best judgment: For anesthetics lasting longer than
90 minutes, unless more frequent monitoring is
medically indicated, the anesthesiologist must
document monitoring in approximately 1-2 hour
intervals.
This applies for all anesthetics: GA, MAC and
Regional.
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Documentation
ASA October 2012 definition of Immediately
Available
It is expected that an anesthesiologist is
immediately available by phone or equivalent
communication device.
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Historically confusing until  ASA House of
Delegates October 17, 2012
“A medically directing anesthesiologist is immediately available
if he/she is in physical proximity that allows the
anesthesiologist to re-establish direct contact with the patient
to meet medical needs and address urgent or emergent clinical
problems. These responsibilities may also be met through
coordination among anesthesiologists of the same group or
department. Differences in design and size of various facilities
and demands of the particular surgical procedures make it
impossible to define a specific time or distance for physical
proximity.”
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Anesthesiologist must personally document
indicated post-anesthesia care he/she provided
Standing orders are sufficient but must be dated
and timed
Summary of post anesthesia visit may be
documented by an anesthesiologist or CRNA
Post anesthesia evaluation must occur within 48
hours of any surgery or procedure and cannot be
performed upon immediate arrival to recovery area
and must be performed after patient can be
appropriately evaluated
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Failed Medical Direction occurs when any
portion of the Medicare rules of Medical
Direction are not performed or documented, or
when a non-allowed activity is performed during
Medical Direction.
Medical Direction is an all or none phenomenon…
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Document accurately
All charts will be reviewed by CAA’s medical
billing company for completeness of Medical
Direction documentation. If they cannot find
clear documentation of Medical Direction, that
charge will be held and a request for
information will be sent to the provider and/or
Site Compliance Coordinator for clarification.
Ask if you have questions or concerns
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However, if you are involved in a failed
medical direction scenario…
It’s OK….
◦ Document accurately
◦ Tell your story and ask questions
◦ It is legal to medically supervise rather than
medically direct.
Although these rules apply to federal guidelines
for federal programs:
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Some commercial insurers have adopted similar
language
Some hospitals/ASCs have placed language in
contracts to ensure Medical Direction