Benefits and Limitations
This section describes program-specific benefits and limitations. Verifying Recipient Eligibility, for general benefit information and limitations.
Administration of anesthesia is a covered service when administered by or directed by a duly licensed physician for a medical procedure that is covered by Medicaid. Medical direction by an anesthesiologist of more than four Certified Registered Nurse Anesthetists (CRNAs) or Anesthesiology Assistants (AA5) concurrently will not be covered.
Administration of anesthesia by an AA is a covered service when the AA has met the qualifications and standards set forth in Rule No. 540-X-7-.51 of the Alabama Board of Medical Examiners. The AA must enroll and receive a NPI to bill the Alabama Medicaid Program. Reimbursement shall be made only when the AA performs the administration of anesthesia under the direct medical supervision of the anesthesiologist.
Administration of anesthesia by a self-employed CRNA is a covered service when the CRNA has met the qualifications and standards set forth in Rule No. 61 O-X-9-.O1 through 61 O-X-9-.04 of the Alabama Board of Nursing Administrative Code. The CRNA must enroll and receive a NPI to bill under the Alabama Medicaid Program. When billing for anesthesia services, providers shall follow the guidelines set forth in the current Relative Value Guide published by the American Society of Anesthesiologists for basic value and time units.
For billing purposes, anesthesia services rendered with medical direction for one CRNA or AA is considered a service performed by the anesthesiologist. The definition of medical direction is an anesthesiologist medically directing four concurrent cases (CRNA/AA) or less. In order to bill for medical direction, the anesthesiologist must be immediately physically available at all times.
Addressing an emergency of short duration, or rendering the requisite CRNA or AA direction activities (listed below in a. through g.), within the immediate operating suite is acceptable as long as it does not substantially diminish the scope of the supervising anesthesiologist’s control. If a situation occurs which necessitates the anesthesiologist’s personal continuing involvement in a particular case, medical direction ceases to be available in all other cases. In order for the anesthesiologist to be reimbursed for medical direction activities of the CRNA or AA, the anesthesiologist must document the performance of the following activities:
• Performs a pre-anesthesia examination and evaluation
• Prescribes the anesthesia plan
• Personally participates in the most demanding procedures in the anesthesia plan, including induction as needed, and emergencies
• Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual
• Monitors the course of anesthesia administration at frequent intervals
• Remains immediately physically available for immediate diagnosis and treatment of emergencies
• Provides indicated post-anesthesia care
A necessary task or medical procedure may be executed while concurrently medically directing CRNAs or AAs only if the task or procedure is one which may be: (1) immediately interruptible without compromising the wellbeing, quality of care, or health of the recipient and (2) is executed in an area close enough to the operating rooms where the CRNAs and AAs are being medically directed and that will permit the physician to remain in compliance with the requirements of being immediately physically available. Examples of an area close enough to the operating rooms” are the Post-Anesthesia Care Unit (PACU) or receiving room. A task or procedure that may be stopped instantly is defined as one of limited difficulty and brief duration so that if it is stopped instantly, it would not interfere with the quality of care, wellbeing, or health of the recipient. There are two exceptions to the above:
1. acting in response to urgencies of short duration or medical emergencies (e.g., ACLS provision, intubation, starting difficult intravenous (IV) lines that without them would reduce the recipient’s quality of care, etc.)
2. labor epidural placement and management
The execution of a trigger point injection or an epidural steroid injection while medically directing is permissible when requested by another physician. The 1:4 ratio should be maintained while the trigger point injection or the epidural steroid injection is being executed. The consult for the execution of the aforementioned may serve as the second, third, or fourth simultaneous case. Therefore the execution of these limited pain services is disallowed while medically directing four simultaneous anesthetics. The ability to respond to urgent or emergent needs in the hospital (operating room, labor and delivery room, or anywhere in the hospital where his/her responsibility lies) may not be decreased at any time and is the responsibility of the anesthesiologist who is medically directing. The intent of this exception is to allow for provision of commonly requested procedures and to improve effectiveness. However, this exception does not include consults to diagnose. Diagnosis of chronic pain and treatment of complex problems is not allowed while simultaneously medically directing CRNAs and AAs.