Revisions CMS made to its interpretive guidelines for hospital-based anesthesia care late last year have raised concerns among some in the anesthesia community who say the edits, which were made outside of the formal rulemaking process, "dramatically alter the scope of practice of anesthesia providers."

That was the assessment the American Society of Anesthesiologists made in a Jan. 18, 2010, letter to the Centers for Medicare and Medicaid Services. In the letter and in an analysis of the revised guidelines posted on its Web site, ASA outlines several new provisions that could have a substantial impact on anesthesia care in non-critical access hospitals that treat Medicare and Medicaid patients (the guidelines do not apply to critical access hospitals or ambulatory surgery centers):

One anesthesia service. Hospitals must integrate all anesthesia and analgesia services, including those delivered in outpatient surgical departments located on- and off-site, into one anesthesia "service" or "department" under the direction of an MD or DO.

Anesthesia vs. analgesia. For the first time, CMS' guidelines distinguish between "anesthesia" (use of medication to produce a blunting or loss of pain perception, voluntary and involuntary movements, autonomic function, and memory and/or consciousness) and "analgesia" (using meducation to relieve pain by blocking pain receptors in the peripheral and/or central nervous system).

Administration and supervision. CMS outlines which types of providers are permitted to administer both anesthesia and analgesia/sedation, with one significant change to previous guidelines — CRNAs are permitted to administer labor epidurals without MD supervision.

"Immediately available" defined. Specifies that when practitioners, such as CRNAs or anesthesiologist assistants, are subject to supervision requirements, the supervising physician must be "physically located within the same area," such as in the same operative suite or procedure room, "and not otherwise occupied in a way that prevents him/her from immediately conducting hands-on intervention, if needed."

Pre-anesthesia evaluation. Must be performed within 48 hours before the administration of the first dose of general, regional or monitored anesthesia. The guidelines detail several new elements that must be included in the evaluation. ASA expressed concern that the 48-hour time period could put an undue burden on hospitals, for example, when cases are scheduled for Monday morning or when a patient must undergo complex pre-op testing. In a response letter to ASA last month, CMS clarified that the evaluation had to be "performed, completely and documented" within 48 hours of the surgical start time, but that some elements of the evaluation, such as time-consuming tests, could be started earlier.

Post-anesthesia evaluation. Must be completed and documented no later than 48 hours after surgery where general, regional or monitored anesthesia have been administered. CMS states the evaluation should not begin "until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation," and "for outpatients, the post-anesthesia evaluation must be completed prior to the patient's discharge."

ASA took issue with the outpatient requirement, arguing that it could "present a barrier to efficiency and patient satisfaction." In its response, CMS said it believes it's "in the interest of patient safety to have an anesthesia professional conclude that the acute effects of anesthesia have sufficiently resolve prior to the patient's discharge," but that other elements of the evaluation could be completed with a post-op phone call after the patient has gone home.

CMS' complete Revised Hospital Anesthesia Services Interpretive Guidelines are available here.

Irene Tsikitas