When anesthesiologists work with other qualified anesthesia providers, such as certified registered nurse anesthetists (CRNA) and anesthesia assistants (AA), they must follow special documentation requirements to be paid for their medical direction of the case.
The medical direction rules apply when an anesthesiologist works with one to four other qualified providers in overlapping cases. If more than four cases overlap, even for a single minute, this is considered to be medical supervision. Most payers will not reimburse the anesthesiologist for this service. The rules also may be different in teaching hospitals, where residents are involved in patient care.
The American Society of Anesthesiologists and Medicare have agreed on seven elements that must be documented for the anesthesiologist to bill his or her medical direction services. Most other payers also require this documentation. The seven elements are:
1. Perform a pre-anesthetic examination and evaluation.
The anesthesiologist must personally perform an exam and evaluation prior to the anesthetic session. Although there are no specific rules about what must be evaluated or examined, it’s not sufficient simply to document that an exam was performed. The specific system(s) or body area(s) examined and the findings also must be documented.
2. Prescribe the anesthesia plan.
The anesthesiologist must personally decide on the appropriate anesthetic for the procedure (e.g., general anesthesia, regional block, monitored anesthesia care [MAC], etc.), and must document that decision.
3. Personally participate in the most demanding procedures in the anesthesia plan, including (if applicable) induction and emergence.
The anesthesiologist must be in the room and must participate in induction and emergence when those are elements of the service provided. If there are other demanding aspects of the service, depending on the type of anesthesia, the anesthesiologist must be in the room during those services and must document his or her presence and participation.
This requirement can be challenging for a busy anesthesiologist with several cases kicking off at the same time; however, if the anesthesiologist cannot be in the room for one of these “most demanding” elements of the case, he or she cannot bill for medical direction (or the entire case).
4. Ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform.
There are no specific special documentation requirements for this element, but the anesthesiologist must be aware that everyone who participates in the anesthesia care is qualified to perform the service. Everyone who participates in the service must sign in to the case, appending his or her license or certification (e.g., MD, CRNA, AA).
5. Monitor the course of anesthesia administration at frequent intervals.
Although it is not necessary for the anesthesiologist to be in the room for the entire case, he or she must provide appropriate monitoring throughout the case. Monitoring means actual presence in the room where anesthesia is being administered.
6. Remain physically present for all key and critical portions of the procedure, and be available for immediate diagnosis and treatment of emergencies.
The sixth rule is the one that seems to trip up anesthesiologists most often. Because the anesthesiologist is providing direction for several cases, and may have new cases starting while other patients are being transported to the post-anesthesia care unit, and still have other ongoing cases, it’s easy for him or her to break medical direction by providing personal anesthesia services to one patient while directing patients in other rooms.
To meet the medical direction requirements, the anesthesiologist cannot be personally providing anesthesia care or handling other services that take more than a few minutes, or that take him or her out of the immediate area where the anesthesia services are being provided.
There are a limited number of services that can be performed without breaking the medical direction rule to remain present and available during the case, including:
- Addressing an emergency of short duration in the immediate area
- Administering an epidural or caudal anesthetic to ease labor pain
- Periodically (rather than continuously) monitoring an obstetrical patient
- Receiving patients entering the operating suite for surgery
- Checking on or discharging patients in the recovery room
- Handling scheduling matters
If the physician leaves the immediate area of the operating suite for other than short durations, devotes extensive time to an emergency case, or is not otherwise available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature and are not billable as medical direction.
7. Provide post-anesthesia care as indicated.
Anesthesia time continues to run, and the anesthesiologist remains responsible for the patient, until the care of the patient is transferred to another caregiver. The anesthesiologist should document any services performed during post-anesthesia time, especially if the patient requires more care due to adverse reactions. Even if the patient is doing fine, the anesthesiologist is expected to document, at a minimum, that the patient is safe to transfer to someone else.
The anesthesiologist must personally document the above seven components. It’s not adequate if someone else documents that he or she did the work, or was present. This information must be documented whenever the anesthesiologist is performing medical direction, no matter what type of anesthesia or analgesia is provided, including MAC.
Some payers may require documentation of these elements for all anesthesia services, even when the anesthesiologist is personally providing the anesthesia service without medical direction.
Other than the anesthesiologist not being allowed to document the required information before the service is performed, there are no specific rules about how monitoring must be documented. For paper records, an anesthesiologist might initial the chart tracking the patient’s vital signs, administration of drugs, and other information each time he or she comes into the room and checks on the patient. In electronic records, the anesthesiologist may add a statement that he or she was present for monitoring each time he or she is in the room checking on the patient, or may document at the end of the record that he or she monitored the patient throughout the course of the case. Either solution is acceptable.
Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS, is internal audit manager at Chan Healthcare. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC National Conferences.