The following questions and answers are a modified version of those developed by the Georgia Society of Anesthesiologists in conjunction with the Georgia Medicare Carrier and published in that carrier’s newsletter in November 1999. Palmetto GBA has reviewed and approved a modified version of this information for publication.
Q1. CMS has stated that the medically directing anesthesiologist may perform other duties concurrently to include:
- Addressing an emergency of short duration in the immediate area
- Administering an epidural or caudal anesthetic to a patient in labor
- Performing periodic, rather than continuous, monitoring of an obstetrical patient
- Receiving patients entering the operating suite for the next surgery
- Checking or discharging patients in the PACU and
- Coordinating scheduling matters
Do you agree that the medically directing anesthesiologist may perform duties such as placement of lines and epidurals in the holding area consistent with this policy?
A1. Yes, we agree that such duties are reasonable, consistent with sound medical practice and would not cause the medically directing anesthesiologist to be in violation of CMS’ rules for medical direction. As long as the medically directing anesthesiologist 'remains physically present and available for immediate diagnosis and treatment of emergencies' (rule number 'vi' of the CMS 'seven commandments'), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions:
- Placement of a Swan-Ganz catheter, central line or arterial line
- Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a 'to follow case')
- Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.
Reference:
Q2. Rule 'v' states that the medically directing anesthesiologist 'monitors the course of anesthesia at frequent intervals.' How often must the anesthesiologist perform such monitoring, and how should this be documented on the chart?
A2. The medically directing anesthesiologist is specifically required to document performing the preanesthesia evaluation, presence at induction and emergence (if applicable). In addition, the anesthesiologist must document his/her presence during the most demanding procedures and that periodic monitoring was performed. CMS intends for the medically directing anesthesiologist to personally perform and document that all seven requirements were met. No specific statement from CMS has been provided regarding the frequency of or the proper format for documentation of periodic monitoring. It is acceptable for the medically directing anesthesiologist to document periodic monitoring by attestation on the anesthesia record or by indicating presence on a timeline if possible.
Reference:
Q3. Please define 'remains physically present and available for immediate diagnosis and treatment of emergencies' as stated rule 'vi.'
A3. We agree that some degree of clinical relevance must be applied to this rule. Differences in geographic design and size of facilities, severity of illness of patients and demands of particular operations prevent any one answer from being sufficient in all cases. It is reasonable to assume that an ‘emergency’ can not be known or dealt with unless physically present. Reasonable clinical judgment must therefore suffice as our best answer.
Q4. Do you agree that there is no definable period of induction or emergence for MAC and regional anesthetic cases, and that therefore the medically directing anesthesiologist need not indicate presence for induction and emergence for these cases?
A4. We agree. In the Federal Register from November 1998, CMS notes: 'However, since 1983, other types of anesthesia care, such as regional anesthetics and monitored anesthesia care have become more common. One of our objectives was to revise the current requirement so that it is consistent with current anesthesia practices. As a result, we have decided that the medically directing physician must be present at induction and emergence for general anesthesia. That final requirement is as follows: The medically directing physician participates in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence.'
We expect the medically directing anesthesiologist to indicate continuous availability for the MAC or regional anesthetic case in the record and to provide monitoring as indicated in Q2 above, but would not expect any notation regarding induction or emergence, since these terms have no meaning for MAC or regional cases.
Q5. Do you agree with the following definition of emergence? 'Emergence, for the purposes of complying with the medical direction requirements of Medicare cases, is the period beginning with the cessation of delivery of anesthetic agents and ending at the time the patient is turned over to the staff of the recovery room or other qualified personnel (ICU, etc).'
A5. We agree.
Q6. May the medically directing anesthesiologist take a short break to eat a meal or use the rest room?
A6. Yes, as long as the medically directing anesthesiologist provides frequent monitoring and remains immediately available.
Q7. If one medically directed case ends at 10:01 a.m. and another begins at 10:01 a.m., do you consider these cases to be concurrent for medical direction purposes?
A7. Yes, we consider these cases to be concurrent.
Q8. When one member of a group practice starts a case and then another member of the same group assumes medical direction during the case for the remainder of that case (the 'intra-operative handoff'), how should this case be submitted?
A8. CMS notes that different members of the same group may provide the pre-operative, intra-operative care of the medically directed patient. Additionally, HCFA (now CMS) noted (in the letter from Mr. Terrence Kay to Ms. Karin Bierstien dated 25 November 1997) that the type of intra-operative handoff mentioned above is permissible, with the billing submitted in the name of the individual involved with the case for the longest time.
Note that in the March 1998 Medicare Advisory, the following statement was made: 'On occasion, a qualified anesthesiologist or CRNA will be relieved from an anesthesia case by another qualified anesthesia provider. When this occurs, the anesthetist that started the case should bill for the entire case.'
Since there are conflicting instructions, we feel it is acceptable to either submit the entire case in the name of the Anesthesiologist who started the case or in the name of the anesthesiologist who spent the most time on the case. Unless CMS clarifies this, either billing method is acceptable.
Q9. A medically directing anesthesiologist is directing two to four anesthetists employed by the group. At the end of the day, when only one room remains under way, the medically directing anesthesiologist relieves the one remaining anesthetist and finishes the case personally. Should the case be submitted as medically directed, personally performed or split bill between the two?
A9. The case cannot be submitted as personally performed unless the entire case is performed by the anesthesiologist (exception in question 10). We feel the case should be submitted as medically directed.
Q10. When an anesthesiologist personally performs the anesthesia services and the anesthesiologist is relieved by a nurse anesthetist for a lunch break, how should the case be submitted?
A10. The current modifiers do not allow accurate reporting of the above situation. We believe the personal performance modifier is the most reasonable in the above circumstance. When personal performance is broken for a brief period of time for personal privileges, the case should still be submitted as personally performed. This should only apply for brief periods during a case and for personal privileges only.
Q11. An epidural catheter is placed for post-operative analgesia. One member of a group places the catheter, and two additional members of the same group make daily visits (CPT code 01996) over the next two days. Should each separate visit indicate the name of the physician involved, or may the entire claim for placement and follow up days be submitted in one name?
A11. Each of the days of daily pain management should be submitted under the group name, identifying the physician who actually performed each service.
Q12. In the event that an anesthesiologist is medically directing one to four concurrent cases and, due to some intervening factor occurring, the medically directing anesthesiologist is unable to be present at emergence, is not immediately available for some portion of the case, or fails to note periodic monitoring on the chart, is it permissible to submit the case with HCPCS modifier QZ, as if the services were provided by a non-medically directed CRNA or AA?
A12. The services of the anesthetist in question could be submitted with HCPCS modifier QZ, even though the anesthesiologist provided some level of supervision. However, the frequency of this should be low. In Q5, the definition of emergence describes a process, not one point in time. Using this definition, most medically directing anesthesiologists will be able to personally participate in this process.
Q13. When should the case be submitted as medically supervised (HCPCS modifier AD) by an anesthesiologist?
A13. Cases are deemed ‘medically supervised’ when an anesthesiologist is involved in more than four concurrent procedures. All five plus cases would be deemed medically supervised. In some instances, the inability to satisfy medical direction criteria may qualify as medical supervision.
Q14. Can an anesthesiologist bill separately for both a CVP line and a Swan-Ganz catheter in the same heart case if each is used for a different purpose?
A14. Assuming that the Swan-Ganz catheter is used for cardiac monitoring and the CVP line is placed for a patient with difficult IV access or other medically indicated reason that is documented on the medical record, both procedures may be covered.
Note: Two distinct catheters are assumed, not a Swan-Ganz counted as both a CVP and a Swan-Ganz.
Q15. In a previous answer, you state that in the situation where one anesthesiologist starts a case and then is relieved by another anesthesiologist in the same practice, the case should be submitted in the name of the anesthesiologist who spends the greatest amount of time on the case. Now assume that an anesthesiologist is medically directing four cases and is called upon to start a fifth case, but is relieved by his partner shortly after the fifth case begins. Can the fifth case be submitted in the name of the partner and still allow the first anesthesiologist to submit the other four cases as medically directed, since his partner relieved him for the majority of the fifth case?
A15. No, the situation as described does not allow for billing of medical direction by the first anesthesiologist. The assumption of the fifth case, no matter how brief, violates the rules for medical direction. The definition of the code for medical supervision (HCPCS modifier AD) notes that supervision, not medical direction, occurs when more than four concurrent anesthetic procedures are under the direction of one anesthesiologist. While we agree with the performance of a number of other duties (as noted above) while medically directing, the assumption of a fifth room would cause all of the five cases to become medically supervised.
Q16. If an anesthesiologist spends ten minutes continuously with a patient in the holding area administering sedative, leaves to set up the OR, and then resumes continuous care in the OR, may he/she include the 10 minutes in the holding area as time spent on anesthesia?
A16. Billing for discontinuous time as discussed is allowable, as long as the time billed reflects only the time that a member of the anesthesiology care team (MD, CRNA, or PA) is in actual attendance with the patient. This should be well documented in the medical record.