Anesthesiologists as ACO Leaders
As hospitals, Ambulatory Surgery Centers (ASCs), and physician providers formulate the transparent partnerships the new rules require to participate in an ACO, it is important to be reminded that anesthesiologists are integral providers to achieve the goals of this new ACO concept. Anesthesiologists have been critical players in the initial assessment and on-going management of patient’s care throughout the perioperative and obstetrical arenas. In addition, Anesthesiology has been a champion for patient safety and has contributed data to the Anesthesia Quality Institute (AQI), for years.
Recent professional editorials have talked about creating a “surgical home” or an Accountable Anesthesia Organization as concepts where anesthesiologists would lead a team dedicated to the goals of an ACO. A recent article published in the Journal of the American Medical Association addressed the potential mistakes in implementing ACOs, particularly in failing to recognize interdependencies (http://jama.ama-assn.org/content/306/7/758.full).
It will be interesting to see the CMS response to the final rules for ACOs when they are made available.
How to Bill for Anesthesia for an Emergency of Short Duration
I was recently asked, “If one of my partners is medically directing a Medicare patient in OR #1 and an emergency C section needs to be performed on another patient because of fetal distress, is medical direction broken if the anesthesiologist begins the emergency case in OR #2 and remains there for 31 minutes, until an on-call CRNA relieves the anesthesiologist?”
CMS muddied the waters by stating that the medically directing anesthesiologist may perform other duties concurrently (sometimes known as the “Six permissible sins” of medical direction). These duties include:
- Addressing an emergency of short duration in the immediate area
- Administering an epidural or caudal anesthetic to a patient in labor
- Performing periodic, rather than continuous, monitoring of an obstetrical patient
- Receiving patients entering the operating suite for the next surgery
- Checking or discharging patients in the PACU
- Coordinating scheduling matters
The emergency case is clearly an emergency (CPT code 99140) and I think we can assume that OR #2 is in the immediate area. So what constitutes “a short duration”? My recommendation is to look at the expected on-call response time as your relative duration. Most anesthesia groups that utilize from-home, on-call for CRNAs, expect them to arrive within 30 minutes of being contacted (group policy statement). In the about example of the anesthesiologist starting the emergency C section and remaining in OR #2 for 31 minutes, would qualify for all three criteria and the case should be billed as medically directed and not subject to decreased reimbursement for broken medical direction (or supervision). My qualified opinion.
Anesthesia groups should use all resources available to them when faced with a situation that they have not encountered before. A few suggested resources are:
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check with their fiscal intermediaries for guidance
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post your situation on a respectable listserv so that your colleagues can share experiences
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contact a consultant that might have experience with this issue
