Question: We are revisiting our Anesthesia Policy and wanted to know whether there has to be a requirement in the Policy for a pre-anesthesia evaluation, intraoperative report, and postanesthesia evaluation for moderate and minimal sedation?

Answer:

The Medicare Conditions of Participation (“CoPs”), at 42 C.F.R. §482.52(b)(1), require a “pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia…[to be] performed within 48 hours prior to surgery or a procedure requiring anesthesia services” (emphasis added).  There are similar requirements for an intraoperative anesthesia record and post-anesthesia evaluation at, respectively, 42 C.F.R. §§482.52(b)(2) & (3).

The Interpretive Guidelines for the CoPs on Anesthesia offer a lengthy definition, consistent with the American Society of Anesthesiologists’ Guidelines, of what constitutes “anesthesia.”  The Interpretive Guidelines for the CoPs instruct:  “CMS, consistent with ASA guidelines, does not define moderate or conscious sedation as anesthesia” and minimal sedation “is also not anesthesia.”

The Interpretive Guidelines later state:

[w]hile current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a pre-anesthesia evaluation performed by someone qualified to administer anesthesia…is not required because moderate sedation is not considered to be ‘anesthesia’ (emphasis in original).

There are similar statements in the Interpretive Guidelines for intraoperative reports and post?anesthesia evaluations.  Since minimal sedation is also not considered “anesthesia” under the CoPs, these statements apply to minimal sedation as well.

Consequently, even though patients receiving minimal, moderate or conscious sedation are required to be monitored and evaluated before, during, and after the procedure by a trained practitioner, there is no requirement under the CoPs that a pre?anesthesia evaluation, intraoperative anesthesia report or post-anesthesia evaluation, as those terms are defined by the Interpretive Guidelines, be performed.  However, you may want to check your particular state’s law or regulations or accreditation entity’s standards on the subject to ensure that those sources do not impose a higher standard than the ones required by the CoPs.