President's Update: More information on revised IGs - Labor Epidurals
Additional Important Information from the ASA on CMS Interpretive Guidelines Revisions 

Dear MSA Member: 

The following communication was sent to the ASA Board of Directors. The notice shares additional helpful information applicable to the recently revised CMS Interpretive Guidelines. The ASA leadership and the ASA staff in Washington DC are to be commended for the effort which went into these revisions. I have included the unedited comments from Mr. Chris Meekins, ASA Manager of Governmental and Political Outreach. 

"ASA has more good news from the revised interpretive guidelines (IGs). In addition to the major victory of getting the 2009 IG language deleted that exempted nurse anesthetists from the physician supervision requirement for labor epidurals, ASA also gained victories in pre- and post-anesthesia evaluation guidelines. 

When the December 2009 IGs were released, ASA members, leadership, and the ASA Regulatory team identified a strategy to achieve meaningful revisions to the IGs that would alleviate member concerns. ASA focused on three areas to change: the labor epidural supervision exemption for nurses, pre-anesthesia requirements, and post-anesthesia requirements. In the new IGs, ASA secured significant changes that benefit ASA members on each of these topics. Many of the changes and clarifications CMS made to the IGs used suggested language provided by ASA. 

As the IGs state, the decision on who provides anesthesia care still rests with the hospital and the one anesthesia service. The IGs actually further solidified the role of the one anesthesia service, which has authority over all sedation and anesthesia in a facility and must be led by the physician Director of Anesthesia Services. 

Immediate Past President Alexander Hannenberg, M.D., who was intimately involved in the regulatory process including meeting with CMS on the topic, praised the new Interpretive Guidelines saying, "ASA achieved major positive revisions to the 2009 Interpretive Guidelines. These changes improve patient safety and continue to emphasize the leadership role an anesthesiologist will play in their facility. These guidelines represent significant improvement over the previous version." 

For pre-anesthesia evaluations: 
  • CMS loosened the timing of the various elements that comprise the pre-anesthesia evaluation. There is now a requirement to complete and document a review of the medical history and interview (if possible given the patient's condition) and examine the patient within 48 hours prior to surgery. The remaining requirements (notation of anesthesia risk, identification of potential anesthesia problems, additional pre-anesthesia data or information and development of the anesthesia plan) can now be performed up to 30 days in advance of the surgery, as long as you review and update (as necessary) within 48 hours of surgery. 

For post-anesthesia evaluations: 
  • Same day surgery - CMS now explicitly permits completion of the post-anesthesia evaluations after patient discharge, as long as it is still within the 48 hour timeframe. 
  • ICU/post-operative sedation patients - CMS now clarifies that documentation of the post-anesthesia evaluation must be made within 48 hours with a notation and reason documenting that the patient was unable to participate in the evaluation. 
  • Long acting regional anesthesia patients - CMS now clarifies that the post-anesthesia evaluation is performed within 48 hours even if the intended affects of anesthesia have not worn off. 

A few individuals have raised questions concerning an item included in the FAQs CMS released with the revised guidelines. The questions focus on this language in the FAQ: "[ED] practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general)." It is important to remember that this is in the FAQ and NOT in the actual IGs. The interpretive guidelines, which will be relied upon by surveyors, state, "We encourage hospitals to address whether the sedation typically provided in the emergency department or procedure rooms involves anesthesia or analgesia." The language goes on to state that the skill set of the clinical staff providing the services must be taken into consideration in adopting the policies, which are developed under the leadership of the physician director of anesthesia services. This is analogous to the policy and privileging considerations for oral surgeons whose anesthesia credentials are tightly circumscribed and typically overseen by anesthesiologists. 

ASA staff, in coordination with the appropriate committees, is working on developing resources for members to use to address this in their local institutions." 

Best Regards, 


Kenneth Elmassian, D.O.
Director American Society of Anesthesiologists President, Michigan Society of Anesthesiologists
517 974 2377


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