Author: Tony Mira
The anticipation is palpable. It’s the early 1970s and you’ve just paid a whopping $7 to hear the Who, live and in concert. The hall is full. The audience is cranked and ready to rock; but before Roger Daltrey can come on stage to sing Pinball Wizard and assure you that We Won’t Be Fooled Again, you must first endure the undercard. That is, you have to sit through 30 minutes of a relatively unknown band that has been cast as the warm-up act. On this night, the little-known troupe is a group by the name of Lynyrd Skynyrd. Not bad for an opener.
It is not unusual to have a main event preceded by the preliminaries, like the main card of a title fight being preceded by lesser bouts. Sometimes, there are follow-up events, as well. For example, after the Who finished their set and walked off the stage, they returned after a few moments in response to the crowd’s demand for an encore. In the practice of anesthesia, there is the main event: the surgical session; but there are also important actions that must precede and follow that session. Our article today will focus on the pre-anesthesia assessment (PAA) and post-anesthesia evaluation.
The Warm-up Act
From a clinical standpoint, anesthesia providers have been taught to perform an exam and evaluation of the patient prior to the beginning of the operative session. This is for purpose of determining the anesthesia plan based on the patient’s physical circumstances and the proposed surgery, as well as explaining the options to the patient and obtaining appropriate consent. These are responsibilities that are quite familiar to all anesthesia providers. However, not all anesthesiologists and anesthetists are aware of the full range of responsibilities surrounding this time with the patient from a compliance perspective.
Medicare has a publication known as the State Operations Manual (SOM). In Appendix A of that manual are set forth certain conditions that hospitals must meet to pass inspection of surveying organizations, such as the Joint Commission. The SOM tells the surveyors what they must look for; and, in turn, the facility is obliged to ensure those items are in place. As it concerns anesthesia in the facility setting, the SOM specifies that there must be a pre-anesthesia assessment. Alright; so far, so good. The details surrounding the PAA, however, are a bit complex and involve precise requirements. Let’s take a further look.
The interpretive guidelines (IGs) found in the SOM first discuss who is allowed to perform the PAA. This is important to understand because we continue to see groups from time to time that are unaware of this standard. The IGs state that the PAA can only be performed by:
- A qualified anesthesiologist
- A doctor of medicine or osteopathy (other than an anesthesiologist)
- A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law
- A CRNA, who is under the supervision of the operating practitioner or anesthesiologist who is immediately available (except in “opt-out” states where such supervision is unnecessary)
- An anesthesiologist’s assistant who is under the supervision of an anesthesiologist who is immediately available
Notice that a nurse practitioner (NP) is not part of this list. So, while certain tasks can be delegated by the anesthesia team to non-anesthesia personnel, the PAA is not one of those tasks. Groups, then, should not include NPs as part of their business plan if the plan is to utilize these providers to perform the exam and evaluation. They are not anesthesia providers, and therefore the PAA is outside of their scope of service.
The timing of the PAA is also important to note. According to the IGs, it must occur within 48 hours prior to any inpatient or outpatient procedure requiring anesthesia services (except in exigent circumstances). However, the PAA process may begin up to 30 days before the procedure. Therefore, any type of test or evaluation by the anesthesia group whose member ultimately provides the anesthesia service during this 30-day period will likely be deemed by the payer as bundled into the PAA and would thus not be separately billable. An exception would be a medically necessary evaluation and management (E/M) service, such as a consult, that represents a service over and above the PAA. Elements that are performed up to 30 days prior to the surgery, must be reviewed and appropriately updated in the provider’s documentation within the 48-hour timeframe.
At a minimum, Medicare states that the PAA must include at least the following elements within the 48-hour time frame:
- 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
- Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure
- Additional pre-anesthesia evaluation, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests)
- Development of the patient’s anesthesia care plan, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or representative) of the risks and benefits of the delivery of anesthesia
It should be noted that Medicare’s interpretive guidelines for the pre-anesthesia evaluation in the ASC setting are more generalized, stating that it must be separate and apart from the surgical H&P and should take place immediately before the procedure.
Executing the Encore
Medicare’s SOM also contains interpretive guidelines relating to the post-anesthesia follow-up. Among other items, the IGs address time limitations for completing the follow-up. Initially, the assessment was to be completed before the patient was discharged from the facility. That instruction was later rescinded. This means that outpatient cases now default to the same requirements as outlined for inpatient cases; that is, you will have 48 hours from the moment the patient is transported to the recovery area to complete the post-anesthesia assessment.
It is important to note that the IGs require the patient’s participation in the applicable portions of the assessment. In addition, the rules specify that the post-anesthesia evaluation cannot begin until the patient is sufficiently awake and aware in order to participate in the evaluation process. If, for some reason, the patient is unable to participate within the 48-hour time window, the provider should document those circumstances in the post-anesthesia note.
The IGs note that the post-anesthesia evaluation may only be completed by those same classes of clinicians who are eligible to conduct the pre-anesthesia assessment. Finally, the post-anesthesia note should include at least the following elements:
- Respiratory function, including respiratory rate, airway patency, and oxygen saturation
- Cardiovascular function, including pulse rate and blood pressure
- Mental status
- Nausea and vomiting
- Postoperative hydration