7 Steps of Medical Direction - PowerPoint Presentation

Slide1

7 Steps of Medical Direction

CMS Billing Compliance Requirements

For AnesthesiologistsSlide2

In addition to the seven steps of medical direction…You may not medically direct more than 4 anesthesia locations at one time…

Medical Direction-ConcurrencySlide3

Changes comingSpring of 2013

Medical Direction-DocumentationSlide4

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

Seven Steps of Medical Direction

(

42 CFR Sec 415.110)Slide5

4) Ensure that any procedures in the anesthesia plan are performed by a qualified individual5) 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

Seven Steps of Medical

Direction

(continued)Slide6

Address an emergency of short duration in the “immediate area” (see “immediately available”)Administer an epidural or caudal anesthetic to relieve labor painPerform periodic rather that continuous monitoring of an obstetrical patientReceive 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

Services allowed while medical directing (Medicare-MCM 15018.C)Slide7

Must be done within 48 hours of surgery/ procedureMust be documentedMust 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.

1. “Perform a pre-anesthetic examination and evaluation”Slide8

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 diseaseNo 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 3Patients with severe systemic diseaseSome 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

CAA recommends the use of the Cleveland

Clinic

modification of the ASA PS classification Slide9

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 CAA recommends the use of the Cleveland clinic modification of the ASA PS classification Slide10

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

2. “Prescribe the anesthesia plan”Slide11

Documentation, Documentation, DocumentationDefinitions of: Induction and Emergence (GA only)

CAA policy

: Pre-signing presence for induction and emergence is not acceptable and is prohibited.

3. “Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence.”Slide12

Not specifically defined by CMSInduction 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.

InductionSlide13

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

EmergenceSlide14

It is the responsibility of CAA and CAA’s Medical Compliance Officer to ensure that records are on file to document anesthesia providers’ qualifications.4. “Ensure that any procedures in the anesthesia plan are performed by a qualified individual”Slide15

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.

5. “Monitor the course of anesthesia administration at frequent intervals”Slide16

DocumentationASA October 2012 definition of Immediately AvailableIt is expected that an anesthesiologist is immediately available by phone or equivalent communication device.

6. “Remain physically present and available for immediate diagnosis and treatment of emergencies”Slide17

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.”

Immediately

AvailableSlide18

Anesthesiologist must personally document indicated post-anesthesia care he/she providedStanding orders are sufficient but must be dated and timedSummary of post anesthesia visit may be documented by an anesthesiologist or CRNAPost 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

7. “Provide indicated post-anesthesia care”Slide19

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…

Failed Medical Direction-Billing

ProtocolSlide20

Document accuratelyAll 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

Failed Medical Direction-Billing ProtocolSlide21

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.

CAA’s practice model

–

Medical

D

irectionSlide22

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

Medical Direction