Documentation Guidelines for Medical Direction by an Anesthesiologist Based on HCFA Final Rule on TEFRA 11/2/98

All States, GR 00-2, March/April, Inside This Issue

The Final Rule on the Tax Equity and Financial Responsibility Act (TEFRA) published by the Centers for Medicare & Medicaid Services (HCFA) on November 2, 1998, included seven requirements for medical direction of anesthesia cases. The additional information that follows each requirement listed below is the documentation expected by CIGNA Government Services (CIGNA Government Services). CIGNA Government Services will use the documentation guidelines when reviewing records for medical direction by an anesthesiologist. Append the modifier -QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) to an anesthesia service HCPCS code to report medical direction by an anesthesiologist.

HCFA’s seven requirements for medical direction are:

1. “Performs a pre-anesthetic examination and evaluation.” The physician should evaluate the patient, performing an appropriate history and physical examination to adequately plan the anesthetic. This must be specifically documented in the medical record.

2. “Prescribes the anesthesia plan.” The physician should personally prescribe and document the anesthesia plan.

3. “Personally participates in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence.” During anesthetics that are not considered to be general, (i.e., regional and/or MAC anesthetic), there is no period of induction or emergence. During general anesthetics the physician should document his or her presence and availability by appropriate signing of the anesthetic record, to indicate in a chronological fashion, participation in induction and emergence. Monitoring of the patient during emergence can occur at any time in the process of emergence.

4. “Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual.” Although no specific documentation in each patient’s record is required, records of current licensure and training certification should be maintained. Knowledge of the individual’s skill set and training is recommended.

5. “Monitors the course of anesthesia administration at frequent intervals.” For a general anesthetic lasting one hour or less, the documentation of presence during induction and at some point during emergence will be sufficient. If the anesthetic lasts longer than an hour, at least one visit to the operating room should be documented.

6. “Remains physically present and available for immediate diagnosis and treatment of emergencies.” No specific documentation is required.

7. “Provides indicated post-anesthesia care.” Standing orders in the Post-anesthesia Care Unit (PACU) are sufficient but should be dated and signed appropriately.

A legible identification of the directing anesthesiologist is required on each page of the record. Change of medical direction should be documented.

Original Source: