CMS Changes Conditions of Participation (CoP) for Anesthesia Services Part 2 of 4
Part II: Anesthesia Administration and Practitioners
According to the regulations, only the following practitioners can administer anesthesia:
- 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 certified registered nurse anesthetist (CRNA), under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed, unless in an opt-out state (As of July, 2009, opt-out states include CA, IA, NE, ID, MN, NH, NM, KS, ND, WA, AK, OR, SD, WI, MT.)
- An anesthesiologist’s assistant, who is under the supervision of an anesthesiologist who is immediately available if needed
The Medical Staff bylaws or rules and regulations must include criteria for determining the anesthesia service privileges to be granted to an individual practitioner and a procedure for applying the criteria to individuals requesting privileges for any type of anesthesia services, including those not subject to the anesthesia administration requirements (sedation). The hospital’s Governing Body must approve the specific anesthesia service privileges for each practitioner who furnishes anesthesia services, addressing the type of supervision required, if any. The privileges granted must be in accordance with state law and hospital policy.
The type and complexity of procedures for which the practitioner may administer anesthesia must be specified in the privileges granted to the individual practitioner. When a hospital permits operating practitioners to supervise a CRNA administering anesthesia, the Medical Staff bylaws or rules and regulations must specify for each category of operating practitioner, the type and complexity of procedures that category of practitioner may supervise. However, individual operating practitioners do not need to be granted specific privileges to supervise a CRNA.
Tips for Compliance
To comply with this section of the regulations, changes in policies and practices may be necessary. Assuring that all areas have been addressed is the only reliable way of avoiding violations on future surveys. Begin by assuring that the following items have been established in policy and practice:
- Define what privileges are required for each level of anesthesia services, including sedation and monitored anesthesia care.
- Align policy and practice regarding the appropriate level of supervision for non-physicians permitted to administer anesthesia under supervised situations.
- Define criteria for determining the anesthesia services privileges for individual practitioners, including those that may administer only sedation.
If the hospital will permit anyone other than an anesthesiologists to supervise a CRNA administering anesthesia, specify in the Medical Staff bylaws or rules and regulations, for each category of operating practitioner, the type and complexity of procedures that category of practitioner may supervise.
- On an ongoing basis, assure that the practices occurs as designed:
- The governing body shows approval of the specific anesthesia privileges granted to individual practitioners and any type of supervision required.
- If operating practitioners are allowed to supervise CRNAs, then define the privileges required to permit this supervision and the type and complexity of procedures where allowed.
Colorado Physicians Sue to Require Medical Direction of CRNAs
September 30, 2010 — A long-simmering turf war between anesthesiologists and certified registered nurse anesthetists (CRNAs) across the country erupted this week into a legal battle in Colorado. As it is with healthcare in general, the conflict centers on matters of quality and quantity — quality of care for patients, quantity of dollars for providers.
The Colorado Medical Society and the Colorado Society of Anesthesiologists yesterday sued Colorado Gov. Bill Ritter Jr. over his decision, announced earlier in the week, to opt out of a Medicare requirement that a CRNA must work under physician supervision for his or her work to be reimbursed. The Centers for Medicare and Medicaid Services gave states this option in 2001, and Colorado is the sixteenth state to exercise it. Most are Western and Great Plains states, where remote rural hospitals may lack an anesthesiologist to supply the supervision.
In their lawsuit, filed in a state circuit court, the Colorado physicians contend that Gov. Ritter’s opt-out decision “will diminish patient safety” and violate the state’s “captain of the ship” doctrine, which puts surgeons in charge of operating room personnel. Seeking a reversal of the governor’s action, the Colorado physicians also contend that the opt-out is contrary to state law, which they say classifies administration of anesthesia by a nurse as a “delegated medical function.”
CRNAs counter that patient care does not suffer when members of their profession work without physician oversight.
“The evidence shows that physician supervision does not have an impact on quality of care,” Paul Santoro, CRNA, and president of the American Association of Nurse Anesthetists (AANA), told Medscape Medical News.
Other states than Colorado that have bailed out of the physician supervision requirement for CRNAs are Alaska, California, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin. Colorado’s opt-out is confined to critical-access hospitals and specified rural hospitals.
