August 2001
Volume 65 |
Number 8
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| Letters
To The Editor |
Mind Your P’s and Q’s — and PA’s
I am a physician assistant (PA) in a New York City Anesthesia
Department. I would like to respond to your “Ventilations”
in the February ASA NEWSLETTER, “In Case You Haven’t
Heard … There Are No Available Anesthesia Providers.”
For a while, I was working with anesthesiologists in the same
capacity as a resident. I was assigned cases with a supervising
anesthesiologist. The chief of service believed this to be legal
as he interpreted the New York State Education Department’s
scope of practice which states, “Medical acts, duties and
responsibilities performed by a physician assistant must be: assigned
to the physician assistant by the supervising physician; within
the scope of practice of the supervising physician; appropriate
to the education, training, and experience of the physician assistant
to whom they are assigned, and; in a facility setting, must be
carried out in accordance with the privileges granted by the hospital.”
However, I discovered that the New York State Department of Health
has a code that states, “Anesthesia shall be administered
in accordance with their credentials and privileges by the following:
anesthesiologists, physicians granted anesthesia privileges, dentists,
oral surgeons, or podiatrists who are qualified to administer
anesthesia under the state law; [nurse anesthetists] and [nurse
anesthetist] students.” Everyone is included except PAs or
AAs [anesthesiologist assistants]. I would like to see this code
changed to allow PAs to practice and so would our attending anesthesiologists,
as they have expressed an interest in giving me more responsibilities
You mention in your editorial that AAs should be considered as
an alternative to ease the shortage of anesthesia providers. I
believe that PAs should also be considered as alternatives in
this field. It is true that PAs and AAs are very distinct professions;
however, the pre-clinical and clinical training of PAs parallel
that of physician’s. Although PAs cannot practice anesthesia
at the completion of their PA training, neither could a physician
upon completion of medical school. PAs obtain on-the-job training
from their supervising physicians, and the broad medical training
that PAs receive, I believe, make them qualified to administer
anesthesia, as permitted by New York regulation.
Kathleen McAllister, RPA-C
Mount Vernon, New York
Editor’s Note – This issue is of critical
importance both from a clinical practice and a political perspective.
Even if anesthesiologists and nurse anesthetists were to miraculously
resolve their differences, are enough people going into nursing
to fill the spots in nurse anesthesia schools?
Better Living Through Preparation
I always enjoy the wisdom of your “Ventilations” and
the comments they draw. As to the biological agents (e.g., anthrax)
you mentioned in the March 2001 NEWSLETTER, it is true
that anesthesiologists have a negligible presence in strategizing
for catastrophe deployment (other than being at extreme exposure
risk in the emergency setting).
Conversely, and it is worth reiterating, anesthesiologists should
be prime movers in managing chemical agent catastrophes. Recall
that nerve agents are ACh inhibitors and act very much like a
whopping dose of succinylcholine. Prompt ventilation, atropine
(and perhaps 2-PAM) can restore life. Still, as you point out,
scarce time is given over to the topic. I believe, as you do,
that our country is woefully unprepared to handle chemical mass
casualties.
As a terrorist tool, chemicals are “ideal” for immediate
panic and killing effect in closed spaces: subway, airplane, sports
stadium, etc. Biologicals, conversely, are slower in onset but
persevere longer. Either one can be an effective weapon that is
almost impossible to detect.
Rudolph H. de Jong, M.D.
Columbia, South Carolina
Code Wars
I am an anesthesiologist who is board-certified by the American
Board of Anesthesiology (ABA). I have received the certificate
in critical care issued by ABA and am a member of a group that
performs anesthesia and critical care for our patients following
open heart, vascular and pulmonary surgery. For many years, our
anesthesia/critical care group, other ASA members and even ASA
itself through its Relative Value Guide has attempted to establish
fair “benchmarks” for coding and billing.
Over the past 20 years, anesthesiologists have made great strides
so that we are treated as other critical care physicians who care
for patients — similar standards, types of orders, progress
notes and THE ABILITY TO BILL FOR APPROPRIATE CARE. The good news
is that overall we have been successful in showing payers (including
Medicare) that we are critical care physicians, every bit as much
as others who might have initially trained in internal medicine,
surgery or pediatrics.
Anesthesiologists appreciate the work of ASA’s Office of
Governmental Affairs in our behalf over many years. However, the
reason for this letter is my disagreement with a consultant’s
statement, listed under Karin Bierstein’s report from the
Office of Governmental Affairs in the April ASA NEWSLETTER.
This statement concerns code 94656—“Ventilation assist
and management, initiation of pressure or volume preset ventilators
for assisted or controlled breathing; 1st day” (actual Current
Procedural Terminology [CPT™] language).
The consultant’s statements (reprinted in the following
sentences) from page 24 of the April NEWSLETTER appear
to undermine anesthesiologists’ efforts. The article in question,
“Top Medicare Billing Risks,” states the following:
risk area # 4: “Billing for initiation of ventilation settings
(94656) for patients who have undergone bypass surgery (00562).”
Note: the words the consultant uses are NOT those of the actual
CPT code. Then, he proceeds to erroneously state: “Initiation
of vent [sic] settings is part of the anesthesia service and thus
NOT billable.” (My emphasis added.)
To be sure, this consultant might be correct in stating that
94656 does occasionally represent a somewhat increased “billing
risk,” necessitating further evidence of a physician’s
orders, progress notes and other documentation. Certainly, some
payers contest paying for 94656! To say that it is “not billable”
might be the consultant’s view, but as a House of Delegates’
member for many years, I do not recall his view as being the position
of ASA or as reflecting language contained in the CPT book.
One issue needs to be clear. Members of our group do not bill
94656 when we simply “drop off” our patients in the
intensive care unit, nor do we bill 94656 for a couple of minutes
in the postanesthesia care unit. We would agree that 94656 is
not appropriate in those instances. However, when we provide the
actual care of postoperative patients according to the CPT book,
the use of the 94656 code is appropriate. The consultant’s
interpretation is incorrect and unfortunate.
Perhaps the wording of this statement, due to its brevity, did
not truly reflect the consultant’s knowledge of the issue,
but this error needs to be retracted before further harm is done
to ASA members. Our group looks forward to a formal, appropriate
clarification from the Office of Governmental Affairs and ASA
leadership.
Under the guidance of Mark J. Lema, M.D., the ASA NEWSLETTER
is a fine publication. He has done an excellent job with editorial
tone and content. Thank you for this opportunity to comment.
Steven R. Young, M.D.
Indianapolis, Indiana
Cracking the Code: Ms. Bierstein Responds
I have discussed Dr. Young’s letter with both L. Charles
Novak, M.D., Chair of the ASA Committee on Economics, and Hal
Nelson, the consultant who supplied the lists of billing risk
areas for my article. They both believe that the published statement:
“4. Billing for initiation of ventilation settings (94656)
for patients who have undergone bypass surgery (00562). Initiation
of vent settings is part of the anesthesia service and thus not
billable,” is accurate and consistent with the views in Dr.
Young’s letter. “Initiation of vent settings is part
of the anesthesia service and thus not billable” is an explanation
of why billing 94656 with 00562 can be a problem and not an independent
policy pronouncement. In many instances, the extent of the anesthesiologist’s
involvement in postoperative ventilation is to order an initial
set of ventilation parameters. A respiratory therapist initiates
those parameters with continuing management by another physician.
Dr. Novak used the phrase “set it and forget it” to
describe this activity. Dr. Young understands that this handoff
is not a separately billable service.
All of us agree that postoperative management of the ventilation
is a separate service and that the specialty of the physician
providing the care is irrelevant. That is the clear intent of
the Correct Coding Initiative, which lists 94656 as a component
code of 00562 but allows the use of the – 59 modifier to
denote a separately billable procedure.
I can see that the published statement may have been ambiguous,
and I hope that I have eliminated any confusion.
Karin Bierstein
Assistant Director of Governmental Affairs (Regulatory)
Image Is Everything
This letter is in reference to the article published in the April
2001 NEWSLETTER by Gifford Eckhout, M.D., and Armin Schubert,
M.D. Every year ASA undergoes an analysis of the supply-and-demand
aspects of the anesthesia realm. It seems to me that this undertaking
is essentially futile. We are not in a shortage of anesthesiologists
currently. In fact, this is essentially the proper amount needed
to keep the market competitive. Many of the groups that today
complain of not being able to hire anesthesiologists were the
same groups that were taking advantage of the ‘glut’
of recent graduates five to seven years ago. I remember when a
new anesthesiology graduate was getting paid less than a nurse
anesthetist and doing twice the work. Almost every one of my friends
in residency has changed jobs at least once. Some went back to
complete a fellowship and not because they disliked the hospital
or staff. They changed jobs because they were not given partnership
or raises and were overworked.
Dr. Eckhout and Schubert believe that it was ASA and the anesthesiology
programs that reduced the number of residents. On the contrary,
it was the fact that medical students who were considering anesthesiology
saw that the residents were having trouble finding jobs. This
is why the number of American graduates has declined. What highly
qualified American graduate wanted to go into a field where you
were not getting offered partnerships and were getting paid next
to nothing? My anesthesiology class was 20 people, with 15 of
them being American-trained doctors. Now my same residency is
almost all foreign-trained doctors. Many groups that I talk to
do not complain about not being able to find anesthesiologists;
they complain about not finding anesthesiologists who meet their
standards of care.
Our future as physicians depends on how others perceive our specialty,
the quality of our residents and the desire of American medical
school graduates to enter our field.
Scott M. Haufe, M.D.
Santa Rosa Beach, Florida
Workforce Prediction Predilections
I read with interest and reflective thought the article by Gifford
Eckhout, M.D., and Armin Schubert, M.D. in the April 2001 issue
of the ASA NEWSLETTER. I compliment the authors for their
content analysis of the present anesthesia workforce. I would,
however, counsel caution, dialogue and continuous trend analysis
to develop an iterative model for action. We need a systematic
process for adjustment over time so we do not repeat past mistakes.
The proposal of increasing graduates by three times by 2005 seems
to be an overstatement, i.e., goes beyond the data. I do not see
this as attainable nor should it be.
Having served as an academic chair (University of North Carolina
at Chapel Hill; 1983-91), as Chair of the Committee on Physician
Resources (1994-96) and on several national ASA task forces over
the last 20 years, I have come to appreciate the need for comprehensive
dialogue before adjusting the anesthesia workforce. Predictions
are not possible. We can, however, use forecasting to generate
scenarios with probabilities. Only by using the concept of multivariate
discriminate analysis for scenario planning can one hope to incorporate
the confounding and intervening variables plus wild cards that
are part of such a complex workforce analysis.
Most of these socioeconomic trends are outside the control of
anesthesia but must be included in any model. For example, the
authors are incorrect about the timing of health care for the
age wave effect, i.e., before 2005. The first baby boomers (a
cohort of 78 million born between 1946-1964) will not turn 65
until 2010. Although the American population is graying, it is
aging quite slowly. Not until 2030, when the youngest baby boomer
has reached 65 years and the entire demographic cohort is subsidized
by Medicare, will the nation’s health care system feel the
true social and economic impact. Moreover, the age wave issue
is not about procedures and acute, episodic care but rather a
new eldercare system focused on chronic diseases. The latter represents
the true “astounding needs of our growing elderly population.”
Finally, I can agree with the authors that systematic planning
using data from inside, but especially outside, of anesthesia
will be fundamental to informed decision-making. I applaud the
efforts by the authors to challenge all of us — the young
and the older debacle group.
Robert W. Vaughan, M.D.
Tucson, Arizona
An Unconscionable Decision About Conscious
Sedation
I have just finished your April “Ventilations” column
and was reminded of a book I recently finished by Noah Gordon
called The Physician. This was the story of a young boy who was
orphaned and placed with a barber-surgeon, learned the trade,
but yearned to do more for his patients. His quest led him to
the Middle East to become a Hakim — a physician.
Throughout the book, a difference is made about two levels of
care. One was administered by barber-surgeons who were very good
at setting broken limbs and amputations but not much else, and
physicians who knew as much medicine as there was at that time
(1100 C.E.) My questions to you: Are we creating a class of barber-surgeons
for an evolving two-tiered health care system by using nurse-practitioners/free-practicing
nurse anesthetists/ and midwives for many patients, and physicians
for those few who can afford or demand personalized care?
And do we wish to return to the time of the Battle of Hastings?
Thanks for the thought-provoking articles!
Paul B. Karas, M.D.
Cheektowaga, NewYork
The Mirror Doesn’t Lie
I just visited a series of disconcerting American Association
of Nurse Anesthetists links supplied in a message from ASA. I
doubt that a milligram of epinephrine could have further raised
my blood pressure or anxiety. I am deeply offended at the desperate
accusations that the authors of these ads make. I know from my
own practice that they are irrational and untrue. There is no
question in my mind that more than a few of our “care team”
colleagues intend to transform a medical specialty into a nursing
discipline. Then I got to thinking, do the nurse anesthetists
have an accomplice in all of this? If so, could this accomplice
be closer to us than we realize?
ASA leadership urges us to fight back with pen, telephone and
monetary contributions. Though I have never supervised a nurse
anesthetist in my life, I have complied. As you follow suit, I
wonder if it would not be worthwhile, perhaps while your own nurse
anesthetists may be “practicing” medicine on your behalf,
to take an honest, self-scrutinizing look in the mirror. Will
you be comfortable with what you see?
Steven R. Lagman, M.D.
Madison, Wisconsin
Reader Likes the Way Editor Tells It
I have read half a dozen of your editorials, and I like your
attitude. You are more in touch with the frustration experienced
by the folks on the frontlines than are many of your peers who
continue to preach how noble it is to be an anesthesiologist.
Our efforts to keep sick people alive during surgery have been
devalued by the American public. Price seems to be more important
than quality. Nurse anesthetists think of us as the enemy, not
their colleagues.
You are telling it like it is.
Douglas J. Martin, M.D.
San Francisco, California
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