[NRSKarenRN]

FLA Nurse Assoc: Nurse Practitioner SCOPE Newsletter June 2005

ADVANCED PRACTICE WITHIN THE LAW Pg2

Physician Supervision, Delegation and Competence

Cynthia A. Mikos, Esq.



Anesthesia and Sedation Risks and Precautions -
Under federal law, it is a condition

of participation in the Medicare
and Medicaid programs for ASCs
that a non-physician anesthetist be
under the supervision of the operating
physician. The requirement for
hospitals varies slightly in that a
CRNA must be under the supervision
of the operating practitioner or an
anesthesiologist who is immediately
available if needed.

States may request that their ASCs
and hospitals be exempted from this
supervision requirement. According
to the American Association of
Nurse Anesthetists’ web site, however,
the only states that had opted
out of the federal supervision
requirement as of November 2004
were Alaska, Idaho, Iowa, Kansas,
Minnesota, Montana, Nebraska,
New Hampshire, New Mexico,

North Dakota, Oregon, and Washington.

Proving Supervision Has Occurred

The Centers for Medicare & Medicaid
Services (CMS) do not define or
specify how to prove supervision.
Nevertheless, having the supervising
physician sign certain anesthesia
orders, evaluations, or records may
be the simplest way for the ASC or
hospital to confirm that supervision
has occurred.

It is OMIC’s understanding that
the role of the treating physician, in
relation to the provision of anesthesia
services, is to (1) determine whether
a patient requires the surgery or
diagnostic procedure, (2) request
that anesthesia be administered, and
(3) determine that the patient is an
appropriate candidate for the procedure
and anesthesia. Therefore, it is
not uncommon for the treating
physician to be asked to sign perioperative
orders for anesthesia, sedation,
and anxiolytic drugs and to co-sign
the pre-anesthesia evaluation conducted
by the nurse anesthetist in
addition to signing the record of
the operation prepared by the circulating
nurse as well as the dictated
operative report. It is less common,
however, for the surgeon to sign the
anesthesia record. If asked to do so,
the ophthalmic surgeon may wish
to clarify with the ASC or hospital
the reason for this requirement,
since proof of the surgeon’s presence
and/or supervision during the
procedure should be ample from
the aforementioned signed orders,
co-signed pre-op evaluation, and/or

operative records.
http://www.omic.com/new/digest/Diges...Fall_04_v9.pdf


Texas: Whether the Board of Nurse Examiners may regulate the selection and administration of anesthesia and the care of an anesthetized patient by a certified registered nurse anesthetist, and related question

The legislature's choice of the word "delegate" as opposed to, and without reference to, "supervise" in section 157.058 of the Occupations Code indicates that a physician may less directly oversee a CRNA's performance than a physician who has delegated tasks under other subdivisions of the Medical Practice Act. While the term "supervise" indicates "general oversight over, to superintend or to inspect," Black's Law Dictionary 1299 (5th ed. 1979); accord XVII Oxford English Dictionary 245 (2d ed. 1989) (defining "supervise"), the term "delegate" denotes a deputization of one person, e.g., a CRNA, to act as the agent of the other, e.g., the physician, see Black's Law Dictionary 383 (5th ed. 1979) (defining "delegate" and "delegation"); accord IV Oxford English Dictionary 411 (2d ed. 1989) (defining "delegate"). Moreover, section 157.058(b) specifies that the physician's order need not "specify a drug, dose, or administrationtechnique," and section 157.058(d) directs us liberally to construe the section to utilize the skills and services of CRNAs. Tex. Occ. Code Ann. § 157.058. All of these factors favor our reading that a physician who properly delegates anesthesia-related tasks to a CRNA is not required, as a matter of law, by the Medical Practice Act to supervise the CRNA's performance of those tasks.
http://www.oag.state.tx.us/opinions/...yn/jc-0117.htm


AANA - Legal Briefs, June 1997 -- The Nature of Supervision


Liability of a surgeon when working
with a nurse anesthetist

[caro3334]

Originally Posted by nurse_god

If you had to place your bets, how much longer before the number of states that pass AA legislation eclipses the number of states that have opted out? The current score is 11 vs. 14.

Oh, no!

[deepz]

Originally Posted by nurse_god

If you had to place your bets, how much longer before the number of states that pass AA legislation eclipses the number of states that have opted out? The current score is 11 vs. 14.

Apples and oranges.

http://allnurses.com/forums/2379951-post17.html

!

[platon20]

Originally Posted by deepz

In all 50 States, CRNAs are legal independent providers.

So all 50 states have opted-out of the Medicare "supervision" rules?

[deepz]

Originally Posted by platon20

So all 50 states have opted-out of the Medicare "supervision" rules?

Apples and oranges.

[ralatek]

Originally Posted by platon20

So all 50 states have opted-out of the Medicare "supervision" rules?

The medicare opt-out has nothing to do with independent practice of a CRNA. It is a billing issue. In those states that have NOT opted out, a CRNA must be supervised in order to receive full reimbursement for MEDICARE cases they do. The supervising physician need not be an anesthesiologist. CRNAs are licensed to practice independent in all 50 states. The individual institutions then set their own policy and procedures that govern nurse anesthesia practice.

[foraneman]

GOOD LORD!

There are 5 different things being compared to each other, none of which has anything to do with the others.

First, the number of states that allow the tiny fraction of anesthesia providers known as Anesthesiology Assistants (AA's) to practice has nothing whatsoever to do with the "opt-out" from the medicare requirement for supervision. Whoever brought that up is an anesthesiologist happily acting the fool and childishly pretending to be a nurse in order to post nonsense on this board. Shame.

Second, the terms SUPERVISION and MEDICAL DIRECTION are terms that were coined by the American Society of Anesthesiologists and adopted by OMIG many years ago when Medicare and Medicaid were in their infancy and developing their reimbursement framework. The ASA hoped these terms would ensure that all Medicare and Medicaid patients would have to be supervised by an anesthesiologist in order for services to be reimbursed. Thus, these terms were/are ONLY useful and relevant for billing purposes. Many major insurance companies also use them to determine the rate they will pay for anesthesia services. For example, if an anesthesiologist is covering 3 CRNA's in 3 operating rooms (medical direction), he/she must be present in the room for induction and emergence and available at all times for emergencies, and check the room at regular intervals in order to be PAID. Whether he/she is there at all, is purely an institutional policy. If he/she wants to bill for the procedure then the above medical direction must take place. As i said, the anesthesia and the CRNA will carry on with or without him/her.

I'll say it once more. THESE TERMS RELATE TO BILLING ONLY! They have NO effect on liability for the surgeon, the CRNA, or the anesthesiologist. Each is responsible for his/her own actions. Supervision, or medical direction when applied to a surgeon/dentist/podiatrist working directly with a CRNA, is a nearly meaningless term. There is no legal definition that has been clearly defined in ANY state. The CRNA bills as NON-MEDICALLY DIRECTED since there is no anesthesiologist to split the fee. The surgeon DOES NOT choose or prescribe the anesthetic. If they DO, they become materially involved in the delivery of the anesthesia and both the CRNA and the surgeon immediately incur greater liability. The CRNA for letting a surgeon dictate the anesthesia, and the surgeon for butting in to an area in which he has no expertise.

The "opt-out" from supervision is about BILLING...PERIOD. And only Medicare and Medicaid billing at that. It has NOTHING to do with the manner in which anesthesia is delivered, or by whom....only who can bill for it. $$$$$$$$$

[Josh L.Ac.]

Originally Posted by foraneman

GOOD LORD!

There are 5 different things being compared to each other, none of which has anything to do with the others.

First, the number of states that allow the tiny fraction of anesthesia providers known as Anesthesiology Assistants (AA's) to practice has nothing whatsoever to do with the "opt-out" from the medicare requirement for supervision. Whoever brought that up is an anesthesiologist happily acting the fool and childishly pretending to be a nurse in order to post nonsense on this board. Shame.

Second, the terms SUPERVISION and MEDICAL DIRECTION are terms that were coined by the American Society of Anesthesiologists and adopted by OMIG many years ago when Medicare and Medicaid were in their infancy and developing their reimbursement framework. The ASA hoped these terms would ensure that all Medicare and Medicaid patients would have to be supervised by an anesthesiologist in order for services to be reimbursed. Thus, these terms were/are ONLY useful and relevant for billing purposes. Many major insurance companies also use them to determine the rate they will pay for anesthesia services. For example, if an anesthesiologist is covering 3 CRNA's in 3 operating rooms (medical direction), he/she must be present in the room for induction and emergence and available at all times for emergencies, and check the room at regular intervals in order to be PAID. Whether he/she is there at all, is purely an institutional policy. If he/she wants to bill for the procedure then the above medical direction must take place. As i said, the anesthesia and the CRNA will carry on with or without him/her.

I'll say it once more. THESE TERMS RELATE TO BILLING ONLY! They have NO effect on liability for the surgeon, the CRNA, or the anesthesiologist. Each is responsible for his/her own actions. Supervision, or medical direction when applied to a surgeon/dentist/podiatrist working directly with a CRNA, is a nearly meaningless term. There is no legal definition that has been clearly defined in ANY state. The CRNA bills as NON-MEDICALLY DIRECTED since there is no anesthesiologist to split the fee. The surgeon DOES NOT choose or prescribe the anesthetic. If they DO, they become materially involved in the delivery of the anesthesia and both the CRNA and the surgeon immediately incur greater liability. The CRNA for letting a surgeon dictate the anesthesia, and the surgeon for butting in to an area in which he has no expertise.

The "opt-out" from supervision is about BILLING...PERIOD. And only Medicare and Medicaid billing at that. It has NOTHING to do with the manner in which anesthesia is delivered, or by whom....only who can bill for it. $$$$$$$$$

Good information and...best smiley icons EVER!

[platon20]

and
(3) determine that the patient is an

appropriate candidate for the procedure
and anesthesia

A surgeon has absolutely zero business doing this. Its the same thing as asking a family practice doctor whether his patient is a good candidate for brain surgery without talking to a brain surgeon first.

Deciding whether a person is appropriate candidate for anesthesia is something ONLY an MDA or CRNA can do. Are you telling me that surgeons are capable of deciding what kind of anesthesia a pt can get? Thats absolute garbage. MDAs dont go up to surgeons and ask them "hey doc do you mind if I use GETA for this pt?"

This is the way it should work: CRNA comes to eval the pt preop. CRNA chooses the anesthesia plan. CRNA writes the orders for the anesthesia plan. CRNA runs the case solo. CRNA monitors the patient at all times and has sole authority, WITHOUT CONSULTING THE SURGEON, to cancel the case if the pt becomes unstable.

Now, the "rules" that somebody posted above dont fit that scenario. It says the surgeon has to order the anesthetic and has to sign some of hte anesthesia-related documents. Thats insane for a surgeon to "order" a drug when he doesnt even know the basics for how it works!

The only thing the surgeon should be doing is writing the op note. The domain of anesthesia belongs SOLELY to MDAs and CRNAs.

[platon20]

Originally Posted by foraneman

Supervision, or medical direction when applied to a surgeon/dentist/podiatrist working directly with a CRNA, is a nearly meaningless term.

So you are claiming that its impossible for a surgeon to be liable for a CRNA's error, even when the state law EXPLICITLY states that some kind of "supervision" is required?

I dont doubt that its a very rare occurrence, but its not as open and shut as you say. If what you said was true, then no surgeon would EVER be sued for anything that happens in terms of bad anesthesia outcomes unless they "interfered" with the anesthesia plan by changing orders or sedation protocols.

The surgeon DOES NOT choose or prescribe the anesthetic.

That doesnt match with the link above that somebody posted:

The Centers for Medicare & Medicaid
Services (CMS) do not define or
specify how to prove supervision.
Nevertheless, having the supervising
physician sign certain anesthesia
orders, evaluations, or records may
be the simplest way for the ASC or
hospital to confirm that supervision
has occurred.

It is OMIC’s understanding that
the role of the treating physician, in
relation to the provision of anesthesia
services, is to (1) determine whether
a patient requires the surgery or
diagnostic procedure, (2) request
that anesthesia be administered, and
(3) determine that the patient is an
appropriate candidate for the procedure
and anesthesia. Therefore, it is
not uncommon for the treating
physician to be asked to sign perioperative
orders for anesthesia, sedation,
and anxiolytic drugs and to co-sign
the pre-anesthesia evaluation conducted
by the nurse anesthetist in
addition to signing the record of
the operation prepared by the circulating
nurse as well as the dictated
operative report.