1. What's New for Anesthesia Practices in 2010
January 4, 2010
I would like to take a moment to wish everyone a Happy New Year and
personally thank you for making ABC's practice management Alert the most
widely read weekly newsletter in the anesthesia community in 2009. It was our
goal, and it remains our goal, to help make anesthesiology the best informed of
all specialties on practice management and health policy issues
There will be many more changes for anesthesia practices in this new year than
we can report here. We are looking forward to keeping you up to date with 51
more Alerts in 2010. We open with the following items:
1. Fifteen-day hold on Medicare claims, January 1- January 15
2. Reporting inpatient visits now that Medicare has eliminated the
consultation codes;
3. Clarification of the requirements for pre- and postanesthesia visits.
1. Fifteen-day hold on claims. Expect your Medicare carrier to hold all claims
for services provided from January 1st through January 15th (ten business days).
The reason for this hold, which CMS announced through its physician listserv on
December 21, 2009, was to avoid the need for retrospective payment
adjustments if Congress were to fix the 21.2% cut announced in the Federal
Register in November. Of course, by the time the listserv subscribers were
notified of the hold, the 21.2% cut had already been put off until March 1, 2010
by the defense appropriations bill passed by the Senate on December 19. Since
the carriers have 15 calendar days to pay clean claims in any event, the hold is
not likely to have much impact. If, for some reason such as a change in its
geographic adjuster, a practice submits charges that are less than the 2010
allowed amount, it will have to resubmit the claims in order to be paid at the
correct level.
2. Reporting inpatient visits without the consultation codes. Effective
January 1, 2010, CMS started denying claims for consultations using the CPT
consultation codes, which the Agency no longer recognizes. The consultation
codes consist of 99241-99244 for office or other outpatient consults and 99251-

2. 99255 for inpatient consultations. Instead of the consultation codes, CMS has
instructed physicians to bill using the new or established patient visit codes.
In the inpatient hospital setting, all physicians (and qualified nonphysicians where
permitted) who perform an initial evaluation and management(E/M) may bill the
initial hospital care codes (99221 – 99223). An anesthesiologist does not need to
be the admitting or primary physician in order to bill an initial E/M service. There
is a new modifier, “-AI” for the “principal physician of record.” Follow-up visits in
the facility setting should continue to be billed as subsequent hospital care visits
(99231 – 99233).
Documenting the request from the referring physician is not required when using
the inpatient E/M codes. The MLN Matters article (MM6740) states:
Conventional medical practice is that physicians making a referral and
physicians accepting a referral would document the request to provide an
evaluation for the patient. In order to promote proper coordination of care,
these physicians should continue to follow appropriate medical
documentation standards and communicate the results of an evaluation to
the requesting physician. This is not to be confused with the specific
documentation requirements that previously applied to the use of the
consultation codes.
Commercial carriers do not have to follow CMS’ lead in withdrawing recognition
from the consultation codes. The vast majority of these carriers have not issued
any guidance on the matter. Some payer contracts may contain language that
automatically applies any new Medicare payment policy to anesthesiologists’
claims. If your practice bills for consultations on a regular basis, you may want to
check any payer contracts that could follow Medicare changes this closely.
If the patient's primary insurance still accepts consultation codes and their
secondary insurance is Medicare, you may bill the service in either of two ways:
(1) bill the primary payer an E/M code that is appropriate for the service, and then
report the amount actually paid by the primary payer, along with the same E/M
code, to Medicare for determination of whether a payment is due; or (2) bill the
primary payer using a consultation code that is appropriate for the service, and
then report the amount actually paid by the primary payer, along with an E/M
code that is appropriate for the service, to Medicare for determination of whether
a payment is due.
The American Medical Association has asked CMS to delay the consultation
policy for a year. CMS has not acted on the request.
3. Clarification of the requirements for pre- and postanesthesia visits.
According to new “Interpretive Guidelines” from CMS, the pre-anesthesia visit
must be performed “within 48 hours prior to any inpatient or outpatient surgery or

3. procedure requiring anesthesia services. The delivery of the first dose of
medication(s) for the purpose of inducing anesthesia . . . marks the end of the 48
hour timeframe.” The pre-anesthesia visit, remember, is not a full H&P or even
medical clearance for surgery (as opposed to anesthesia) and the physician may
still report an E/M service if s/he documents the elements of the selected code.
The Interpretive Guidelines are are not intended to affect billing for Medicare Part
B services. Rather, they are instructions to the surveyors who assess hospitals’
compliance with the Medicare Part A Conditions of Participation. They can be
found in Appendix A to the State Operations Manual. (The Manual posted on the
CMS website has not yet been updated to include the December 11, 2009
revisions, which we are posting on our own website for your convenience.)
The surveyors may be employees of the State agency that accredits healthcare
facilities, or they may be physicians contracted by The Joint Commission to
perform accreditation surveys under TJC’s “deemed” authority. Both State
agency and TJC surveyors must ensure that the hospitals meet the Conditions of
Participation as spelled out in the relevant federal regulations (42 C.F.R. §
482.52 for anesthesia services) and in Appendix A’s Interpretive Guidelines and
Survey Procedures.
As revised in December 2009, effective immediately, the pre-anesthesia
evaluation of the patient should include, “at a minimum:”
 Review of the medical history, including anesthesia, drug and allergy
history;
 Interview and examination of the patient;
 Notation of anesthesia risk according to established standards of practice
(e.g. ASA classification of risk);
 Identification of potential anesthesia problems, particularly those that may
suggest potential complications or contraindications to the planned
procedure (e.g., difficult airway, ongoing infection, limited intravascular
access);
 Additional pre-anesthesia evaluation, if applicable and as required in
accordance with standard practice prior to administering anesthesia (e.g.,
stress tests, additional specialist consultation); and
 Development of the plan for the patient’s anesthesia care, including the
type of medications for induction, maintenance and post-operative care
and discussion with the patient (or patient’s representative) of the risks
and benefits of the delivery of anesthesia.
Requirements for the postanesthesia visit have also been modified in the new
Interpretive Guidelines. Over the years many anesthesiologists have asked
whether it is acceptable to perform the postanesthesia visit in the PACU. The
regulation, §482.52(b)(3), provides only that a postanesthesia evaluation must be
completed and documented “no later than 48 hours after surgery or a procedure

4. requiring anesthesia services.” Many consultants including ASA staff have
answered that as long as the postanesthesia visit occurs after anesthesia time
has ended, it may be performed in the PACU.
The Interpretive Guidelines have now clarified the applicable principles. The
postanesthesia evaluation may be conducted in the PACU as long as the patient
is sufficiently recovered to participate purposefully in the assessment:
The calculation of the 48-hour timeframe begins at the point the patient is
moved into the designated recovery area. Except in cases where post-
operative sedation is necessary for the optimum medical care of the patient
(e.g., ICU), the evaluation generally would not be performed immediately at
the point of movement from the operative area to the designated recovery
area. Accepted standards of anesthesia care indicate that the evaluation may
not begin until the patient is sufficiently recovered from the acute
administration of the anesthesia so as to participate in the evaluation, e.g.,
answer questions appropriately, perform simple tasks, etc. The evaluation
can occur in the PACU/ICU or other designated recovery location. For
outpatients, the post-anesthesia evaluation must be completed prior to the
patient’s discharge. The elements of an adequate post-anesthesia evaluation
should be clearly documented and conform to current standards of
anesthesia care, including:
 Respiratory function, including respiratory rate, airway patency, and
oxygen saturation;
 Cardiovascular function, including pulse rate and blood pressure;
 Mental status;
 Temperature;
 Pain;
 Nausea and vomiting; and
 Postoperative hydration.
Depending on the specific surgery or procedure performed, additional types
of monitoring and assessment may be necessary.
There are other items of interest in the Revised Hospital Anesthesia Services
Interpretive Guidelines, notably a definition of “immediately available” as the
anesthesiologist’s being “physically located within the same area as the CRNA,
e.g., in the same operative suite, or in the same labor and delivery unit, or in the
same procedure room, and not otherwise occupied in a way that prevents
him/her from immediately conducting hands-on intervention, if needed.”
The most controversial provisions of the revised Interpretive Guidelines are
based on a tortuous effort to define "anesthesia" as distinct from conscious
sedation, minimal sedation, anxiolysis– and as distinct from "analgesia". The
patent objective of the anesthesia/ analgesia differentiation was to declare labor

5. epidurals to be non-anesthesia services that could be performed by
unsupervised nurse anesthetists even in states that have not opted out of the
requirement that CRNAs provide anesthesia under the supervision of an
anesthesiologist of the "operating practitioner."
The issuance of the Revised Interpretive Guidelines immediately gave rise to a
listserv discussion among Anesthesia Administration Assembly (AAA) members
as to whether anesthesiology practices could indeed start to relieve their
physicians from supervising CRNAs in the labor and delivery suite. It would
appear that the new interpretation permits precisely that. It is important to note,
however, that the federal regulations themselves have not changed at all- the
CMS Survey & Certification personnel who write the Interpretive Guidelines have
simply rewritten surveyor instructions in a way designed to permit CRNAs to
perform spinals and epidurals for obstetrical patients in every hospital willing to
grant the CRNAs such privileges, regardless of whether the state in which the
hospital is located has opted out of the Medicare Conditions of Participations'–
supervision requirement.
Whether this rewrite will stand remains to be seen. As stated in its Analysis of
New Anesthesia Interpretive Guidelines for Hospitals, "ASA is concerned that
these changes may not have followed provisions in the Administrative
Procedures Act and will address this issue as well as other concerns related to
the guideline revisions with CMS." For the time being, the conservative course of
action would be to defer any staffing changes until the matter is fully clarified.
Despite closing on a note of confusion, we promise you that we will continue to
do our best to shed early and practical enlightenment on the many changes that
lie ahead for anesthesia practices.
With best wishes,
Tony Mira
President and CEO
If you have any questions or would like additional information please call 517-
787-6440 x 4113, send an email to info@anesthesiallc.com, or visit our website
at www.anesthesiallc.com.