Got this by email today.
“The Rule of Two
It’s easy. Both the Centers for Medicare and Medicaid Services (CMS) and the American Society of Anesthesiologists (ASA) have made it clear. If you, as an anesthesia teacher, are involved in even one case involving a resident or a student registered nurse anesthetist (SRNA), you cannot run more than two concurrent cases. That means, if you’re a teaching anesthesiologist, you can oversee up to (a) two resident cases, or (b) one resident case and one medically directed case, or (c) two SRNA cases, but no more. It’s the rule of two. You cannot be involved in a third case. (Yes, there is an exception, which we will get to later.) Similarly, if you are a teaching CRNA, you cannot supervise more than two SRNA cases.
Letter of the Law
Well, how do you know that picking up a third or fourth case in the teaching context is noncompliant? Beginning with the January 2010 update to the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50B, we’re told that the personally performed rate for an anesthesiologist applies where, among other things:
The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules.
The clear implication is that, since 2010, an anesthesiologist cannot be involved in more than two concurrent cases where even one involves a resident in order to bill the AA modifier (indicating personal performance). Where a teaching anesthesiologist is involved in two simultaneous resident cases, the anesthesiologist can bill AA for each.
In Sec 50C of that same MCPM chapter, we find the following:
The medical direction rules apply to cases involving student nurse anesthetists if the physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern or resident.
Again, the teaching anesthesiologist is limited to two cases if even one involves an SRNA. “Fine, but what about a teaching CRNA?” In a November 2009 transmittal (1859) from CMS, we read the following instruction:
[T]he teaching CRNA can be paid the full fee for his/her involvement in each of two concurrent anesthesia cases with student nurse anesthetists. To bill the base units, the teaching CRNA must be present with the student nurse anesthetist during the pre and post anesthesia care for each of the two cases involving student nurse anesthetists.
See a pattern developing? Again, the limit is two cases.
Exception to the Rule
People often talk about “the exception that proves the rule”; and, yes, there is an exception to the otherwise ironclad rule of two. But, if you look closely, it’s not really an exception. Let’s take a look at it. Both CMS and the ASA have acknowledged that an anesthesiologist can be involved in up to four “SRNA cases.” “But, you said that’s not allowed!” Yes, yes, but here’s what’s really going on with this so-called exception. You can oversee up to four SRNA rooms
only where a CRNA is continually present in each of those rooms. That is, you’ve got four CRNAs with the four SRNAs. So, what’s really taking place in this scenario is the anesthesiologist is actually medically directing the four CRNAs, each of whom happens to have a student in the room with them.
So, to wind this up, we urge and adjure you to have protocols in place within your practice that will preclude, prohibit and prevent picking up a third case where any case involves a resident or SRNA (who is without a CRNA in the SRNA room). Raise this issue with your partners. Bring it up in your meetings. Train your staff. We’re asking you to toe the line on this one, because this one really matters.“
