1. 7 Steps of Medical Direction
CMS Billing Compliance Requirements
For Anesthesiologists

2. Medical Direction-Concurrency
In addition to the seven steps of medical direction…You may not medically direct more than 4 anesthesia locations at one time…

3. Medical Direction-Documentation
Changes coming Spring of 2013

4. Seven Steps of Medical Direction (42 CFR Sec 415.110)
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

5. Seven Steps of Medical Direction (continued)
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

6. Services allowed while medical directing (Medicare-MCM 15018.C)
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

7. 1. “Perform a pre-anesthetic examination and evaluation”
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.

8. CAA recommends the use of the Cleveland Clinic modification of the ASA PS classification
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
ASA PS 2
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
ASA PS 3
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

9. Preoperative Health Status
CAA recommends the use of the Cleveland clinic modification of the ASA PS classification
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

10. 2. “Prescribe the anesthesia plan”
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

11. Documentation, Documentation, Documentation
3. “Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence.”
Documentation, Documentation, Documentation
Definitions of: Induction and Emergence (GA only)
CAA policy: Pre-signing presence for induction and emergence is not acceptable and is prohibited.

12. Induction 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.

13. Emergence
Emergence is defined as a continuum that begins as the anesthetic level is being reduced until the patient is stable in the PACU.

14. 4. “Ensure that any procedures in the anesthesia plan are performed by a qualified individual”
It is the responsibility of CAA and CAA’s Medical Compliance Officer to ensure that records are on file to document anesthesia providers’ qualifications.

15. 5. “Monitor the course of anesthesia administration at frequent intervals”
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.

16. 6. “Remain physically present and available for immediate diagnosis and treatment of emergencies”
Documentation
ASA October 2012 definition of Immediately Available
It is expected that an anesthesiologist is immediately available by phone or equivalent communication device.

17. Immediately Available
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.”

18. 7. “Provide indicated post-anesthesia care”
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

19. Failed Medical Direction-Billing Protocol
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…

20. Failed Medical Direction-Billing Protocol
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

21. CAA’s practice model – Medical Direction
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.

22. Medical Direction
Although these rules apply to federal guidelines for federal programs:
Some commercial insurers have adopted similar language
Some hospitals/ASCs have placed language in contracts to ensure Medical Direction