Knowing of your interest in ensuring patient access to safe, cost-effective anesthesia care, I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has now clarified and confirmed that anesthesiologist assistants (AAs) may not bill Medicare for nonmedically directed (billing code QZ) anesthesia services as CRNAs are educated and authorized to do.
In a policy transmittal dated May 30, 2013, the agency clarified the distinctions between CRNAs, who may practice autonomously and bill Medicare for their services, and AAs, whose services are covered by Medicare when they are medically directed by an anesthesiologist. Transmittal 2716 amends Chapter 12 of the Medicare Claims Processing Manual governing Medicare Part B coverage of anesthesia care.
Though Medicare Administrative Contractors (MACs) long held that AAs may not bill Medicare QZ, the Palmetto GBA MAC serving the states of California, Hawaii, Nevada, North Carolina, South Carolina, Virginia and West Virginia published an email April 24 stating, "Palmetto GBA has received guidance that the QZ HCPCS modifier is also to be used for an Anesthesiologist Assistant (AA) service performed without medical direction." Noting that the Palmetto GBA action was inconsistent with Medicare regulations and payment manuals that say an AA is a "person who works under the direction of an anesthesiologist," AANA addressed the issue directly with Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS).
The action taken by CMS represents an important development in anesthesia services coverage, clarifying what we already know: that CRNA and AA educational preparation and services are not the same, and that the Medicare program recognizes them differently. While Medicare recognizes CRNA services provided autonomously and with anesthesiologist medical direction, in contrast the agency only recognizes AA services under anesthesiologist medical direction. Many public and commercial health plans covering CRNA services follow Medicare's lead.
We commend the Medicare agency for having an open ear to AANA's concerns, following and appropriately clarifying the law, and promoting patient access to safe and cost-effective anesthesia care.
For all you do for the patients, practice and profession of nurse anesthesia, thank you.
Only 1 ACT practice were the elements of medical direction for every case done.
Only 29% of ACT practices indicated that a MDA did the preoperative assessment.
I had not seen this article - thanks for bringing it up.
It has several factual errors. They can't even get the 7 TEFRA requirements correct - great "peer review" - and the author actually lists 8 of them in their table even though one item is omitted entirely and others separated into multiple items.
The 1st TEFRA requirement is that the anesthesiologist "evaluate and examine" every patient pre-operatively. The requirement is not "writes the pre-operative assessment". In each and every ACT practice I've ever been involved with in more than 30 years of practice, an anesthesiologist has personally evaluated and examined every single patient that I have been involved with. Every one. They signed the pre-op evaluation form on every patient - every single one of them. The TEFRA requirements do not preclude other members of the anesthesia team from conducting a pre-op examination as well, and that happens quite frequently in many practices, particularly those that have pre-op "clinics" that see patients a few days or weeks prior to surgery.
Items 2 and 3 are correct.
The authors left out the 4th requirement altogether, which is that any procedures not personally performed by the anesthesiologist are performed by a qualified anesthetist.
Item 5 is the requirement for frequent checks, listed as item 4 in the author's article.
Item 6 is that the anesthesiologist be present and available throughout the procedure and not performing any concurrent procedures. The authors actually created a separate item regarding concurrent procedures, I guess to make up for the one they missed. Note that "concurrent procedures" does not include things like performing blocks in pre-op on another patient or perhaps placing a labor epidural.
"Journal Anesthesiology Confirms that Anesthesiologist Supervision Often Lapses
Lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs, according to an important new study in the March issue of the journal Anesthesiology. The study, titled "Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics," looks at over 15,000 anesthesia records in one leading U.S. hospital and raises critical issues about propriety and compliance in the most common and costly model of anesthesia delivery at a time when quality and cost-effectiveness are white-hot healthcare issues at every level."
Interesting article as well, which I read last year. It has generated quite a lot of discussion and comment. A review of 15,000 anesthesia records from our practice would show exactly zero concurrency problems, so I'm not quite sure where the issues are with this particular hospital. It's simply not that difficult to deal with concurrent medical direction if one pays attention. We have it down to an art at our facilities. Let me know if you'd like to set up a site visit to see how easily it can be accomplished in the real world.
Interesting article as well, which I read last year. It has generated quite a lot of discussion and comment. A review of 15,000 anesthesia records from our practice would show exactly zero concurrency problems, so I'm not quite sure where the issues are with this particular hospital. It's simply not that difficult to deal with concurrent medical direction if one pays attention. We have it down to an art at our facilities. Let me know if you'd like to set up a site visit to see how easily it can be accomplished in the real world.
Okay, first you say show me the article and then you say I have already read this. You are doing nothing but seeking to start arguments on here.
2. There is absolutely no possible way that your workplace would have 0 deficiencies in over 15,000 cases. The TEFRA rules are to hard to follow and one emergency in another room could easily cause the TEFRA rules not to be followed. You would have to be so overstaffed with anesthesiologists that the hospital subsidies for your anesthesiology group would be outrageous.
3. Every ACT I have been to and every CRNA that I have talked to that has worked in ACT practices have said that TEFRA are difficult to abide by and often missed.
Okay, first you say show me the article and then you say I have already read this. You are doing nothing but seeking to start arguments on here.
2. There is absolutely no possible way that your workplace would have 0 deficiencies in over 15,000 cases. The TEFRA rules are to hard to follow and one emergency in another room could easily cause the TEFRA rules not to be followed. You would have to be so overstaffed with anesthesiologists that the hospital subsidies for your anesthesiology group would be outrageous.
3. Every ACT I have been to and every CRNA that I have talked to that has worked in ACT practices have said that TEFRA are difficult to abide by and often missed.
Again - your comment was "the vast majority of anesthesia cases do not meet TEFRA requirements" That comment is not supported by the study you just quoted. The editorial comment
Journal Anesthesiology Confirms that Anesthesiologist Supervision Often Lapses
Lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs
is not part of the study.
You should look up how TEFRA deals with emergencies, and worst case (correct me if my understanding of billing is incorrect) the cases can be billed to reflect supervision rather than medical direction.
My group takes no hospital subsidies whatsoever. We have 24/7 in-house coverage with MD's and anesthetists, and each and every case fully complies with TEFRA requirements.
Again - your comment was "the vast majority of anesthesia cases do not meet TEFRA requirements" That comment is not supported by the study you just quoted. The editorial comment
Journal Anesthesiology Confirms that Anesthesiologist Supervision Often Lapses
Lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs
is not part of the study.
You should look up how TEFRA deals with emergencies, and worst case (correct me if my understanding of billing is incorrect) the cases can be billed to reflect supervision rather than medical direction.
My group takes no hospital subsidies whatsoever. We have 24/7 in-house coverage with MD's and anesthetists, and each and every case fully complies with TEFRA requirements.
WRONG....AAs CANNOT bill for medical supervision!!! That was a whole post! You have Anesthesiologists, CRNA, and anesthesiologist assistants. Only the first two groups should call themselves anesthetists, and anesthesiologists rarely call themselves anesthetists in this country. AAs calling themselves anesthetists is nothing but attempt to pass themselves off as CRNAs.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Clearly this is a hot topic amongst the Anesthesia Community and cannot be solved here.
As per the Terms of Service......allnurses.....
.promotes the idea of lively debate. This means you are free to disagree with anyone on any type of subject matter as long as your criticism is constructive and polite. Please refrain from name-calling. This is divisive, rude, and derails the thread. Our first priority is to the members that have come here because of the flame-free atmosphere we provide. There is a zero-tolerance policy here against personal attacks. We will not tolerate anyone insulting other's opinion nor name calling.
Our call is to be supportive, not divisive.
multiple posts have been edited/deleted.....Sometimes you have to agree to disagree.....without being disagreeable....or the thread will be closed and points assigned
WRONG....AAs CANNOT bill for medical supervision!!! That was a whole post! You have Anesthesiologists, CRNA, and anesthesiologist assistants. Only the first two groups should call themselves anesthetists, and anesthesiologists rarely call themselves anesthetists in this country. AAs calling themselves anesthetists is nothing but attempt to pass themselves off as CRNAs.
Again, there are exceptions built in to the rule to deal with emergencies.
Clearly this is a hot topic amongst the Anesthesia Community and cannot be solved here.
As per the Terms of Service......allnurses.....multiple posts have been edited/deleted.....Sometimes you have to agree to disagree.....without being disagreeable....or the thread will be closed and points assigned
Ahhh. Now this is the Allnurses I remember. Maybe we should go back to prior screening of posts to maintain a genteel atmosphere.
I think a better solution would be to restrict the forum to only CRNAs . No AAs,students or people thinking about this profession. They have their own sub forums.
I think a better solution would be to restrict the forum to only CRNAs . No AAs,students or people thinking about this profession. They have their own sub forums.
Basically, as long as they are up front with their professional background and seek to actually state a factual opinion with facts instead of stating in one post there is no evidence and then when the evidence is provided state they have already read and discussed the said evidence then everyone is welcome.
Specializes in Anesthesia, Pain, Emergency Medicine.
I agree with this. Invariable this starts in ALL NP forums because NON NPs inject incorrect information and many times leads to a war.
Why on earth allow an AA into a CRNA forum.
I think a better solution would be to restrict the forum to only CRNAs . No AAs,students or people thinking about this profession. They have their own sub forums.
Specializes in Education, FP, LNC, Forensics, ED, OB.
If professionals cannot debate respectfully, they need to bypass the thread/forums.
Those coming on who are educated professionals in other disciplines (non-nursing) and come with an agenda to be divisive only, we don't need this.
This IS a nursing forum and we invite others from differing disciplines to cone in and discuss, but looks like the majority of the ones we've invited to partake in discussion, only want to be divisive, trollish, argumentative, naive, and disrespectful; adding nothing positive to the discussion about the CRNA. There are other forums these individuals can go to and will be more than welcome there.
So, from this point forward, if the debates cannot be respectful , then posts will be removed and points assigned.
jwk
1,102 Posts
I had not seen this article - thanks for bringing it up.
It has several factual errors. They can't even get the 7 TEFRA requirements correct - great "peer review" - and the author actually lists 8 of them in their table even though one item is omitted entirely and others separated into multiple items.
The 1st TEFRA requirement is that the anesthesiologist "evaluate and examine" every patient pre-operatively. The requirement is not "writes the pre-operative assessment". In each and every ACT practice I've ever been involved with in more than 30 years of practice, an anesthesiologist has personally evaluated and examined every single patient that I have been involved with. Every one. They signed the pre-op evaluation form on every patient - every single one of them. The TEFRA requirements do not preclude other members of the anesthesia team from conducting a pre-op examination as well, and that happens quite frequently in many practices, particularly those that have pre-op "clinics" that see patients a few days or weeks prior to surgery.
Items 2 and 3 are correct.
The authors left out the 4th requirement altogether, which is that any procedures not personally performed by the anesthesiologist are performed by a qualified anesthetist.
Item 5 is the requirement for frequent checks, listed as item 4 in the author's article.
Item 6 is that the anesthesiologist be present and available throughout the procedure and not performing any concurrent procedures. The authors actually created a separate item regarding concurrent procedures, I guess to make up for the one they missed. Note that "concurrent procedures" does not include things like performing blocks in pre-op on another patient or perhaps placing a labor epidural.
Item 7 is correct in the article.