CMS SOM App. A, Tag A-1001

The organization of anesthesia services must be appropriate to the scope of the

services offered. Anesthesia must be administered only by --

(1) A qualified anesthesiologist;

(2) A doctor of medicine or osteopathy (other than an anesthesiologist);

(3) A dentist, oral surgeon, or podiatrist who is qualified to administer

anesthesia under State law;

(4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of

this chapter, who, unless exempted in accordance with paragraph (c) of this

section, is under the supervision of the operating practitioner or of an

anesthesiologist who is immediately available if needed; or

(5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter,

who is under the supervision of an anesthesiologist who is immediately

available if needed.

§482.52(c) Standard: State Exemption

(1) A hospital may be exempted from the requirement for MD/DO supervision

of CRNAs as described in paragraph (a)(4) of this section, if the State in

which the hospital is located submits a letter to CMS signed by the

Governor, following consultation with the State’s Boards of Medicine and

Nursing, requesting exemption from MD/DO supervision of CRNAs. The

letter from the Governor must attest that he or she has consulted with State

Boards of Medicine and Nursing about issues related to access to and the

quality of anesthesia services in the State and has concluded that it is in the

best interests of the State’s citizens to opt-out of the current MD/DO

supervision requirement, and that the opt-out is consistent with State law.

(2) The request for exemption and recognition of State laws, and the

withdrawal of the request may be submitted at any time, and are effective

upon submission.

Interpretive Guidelines §482.52(a) and (c)

Who May Administer Anesthesia

Topical/local anesthetics, minimal sedation, moderate sedation

The requirements at §482.52(a) concerning who may administer anesthesia do not apply

to the administration of topical or local anesthetics, minimal sedation, or moderate

sedation. However, the hospital must have policies and procedures, consistent with State

scope of practice law, governing the provision of these types of anesthesia services.

Further, hospitals must assure that all anesthesia services are provided in a safe, well-organized manner by qualified personnel.

General anesthesia, regional anesthesia and monitored anesthesia, including deep

sedation/analgesia, may only be administered by:

• A qualified anesthesiologist;

• An MD or DO (other than an anesthesiologist);

• A dentist, oral surgeon or podiatrist who is qualified to administer anesthesia

under State law;

• A CRNA who is supervised by the operating practitioner or by an anesthesiologist

who is immediately available if needed; or

• An anesthesiologist’s assistant under the supervision of an anesthesiologist who is

immediately available if needed.

Administration by an MD/DO/dentist/oral surgeon/podiatrist

The hospital’s anesthesia services policies must address the circumstances under which

an MD or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is

permitted to administer anesthesia. In the case of a dentist, oral surgeon or podiatrist,

administration of anesthesia must be permissible under State law and comply with all

State requirements concerning qualifications. Hospitals should conform to generally

accepted standards of anesthesia care when establishing policies governing anesthesia

administration by these types of practitioners as well as MDs or DOs who are not

anesthesiologists.

Administration by a CRNA

Unless the hospital is located in a State that has chosen to opt out of the CRNA

supervision requirements, a CRNA administering general, regional and monitored

anesthesia must be supervised either by the operating practitioner who is performing the

procedure, or by an anesthesiologist who is immediately available.

Hospitals should conform to generally accepted standards of anesthesia care when

establishing policies for supervision by the operating practitioner. An anesthesiologist is

considered “immediately available” when needed by a CRNA under the

anesthesiologist’s supervision only if he/she is physically located within the same area as

the CRNA, e.g., in the same operative/ procedural suite, or in the same labor and delivery

unit, and not otherwise occupied in a way that prevents him/her from immediately

conducting hands-on intervention, if needed.

If the hospital is located in a State where the Governor has submitted a letter to CMS

attesting that he or she has consulted with State Boards of Medicine and Nursing about

issues related to access to and the quality of anesthesia services in the State and has

concluded that it is in the best interests of the State’s citizens to opt-out of the current

physician supervision requirement, and that the opt-out is consistent with State law, then

a hospital may permit a CRNA to administer anesthesia without operating practitioner or

anesthesiologist supervision. (A list of States that have opted out of the CRNA

supervision requirement may be found at

http://www.cms.hhs.gov/CFCsAndCoPs/02_Spotlight.asp)

A CRNA is defined in §410.69(b) as a “registered nurse who:

(1) Is licensed as a registered professional nurse by the State in which the nurse

practices;

(2) Meets any licensure requirements the State imposes with respect to nonphysician anesthetists;

(3) Has graduated from a nurse anesthesia educational program that meets the

standards of the Council on Accreditation of Nurse Anesthesia Programs, or such other

accreditation organization as may be designated by the Secretary; and

(4) Meets the following criteria:

(i) Has passed a certification examination of the Council on Certification of

Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or any other

certification organization that may be designated by the Secretary; or

(ii) Is a graduate of a program described in paragraph (3) of this definition

and within 24 months after that graduation meets the requirements of paragraph (4)(i) of

this definition.”

Administration by an Anesthesiologist’s Assistant

An anesthesiologist’s assistant may administer anesthesia when under the supervision of

an anesthesiologist. The anesthesiologist must be immediately available if needed. An

anesthesiologist is considered “immediately available” to assist the anesthesiologist’s

assistant under the anesthesiologist’s supervision only if he/she is physically located

within the same area as the anesthesiologist’s assistant, e.g., in the same

operative/procedural suite, or in the same labor and delivery unit, and not otherwise

occupied in a way that prevents him/her from immediately conducting hands-on

intervention, if needed.

An anesthesiologist’s assistant is defined at §410.69(b) as a “person who-

(1) Works under the direction of an anesthesiologist;

(2) Is in compliance with all applicable requirements of State law, including any

licensure requirements the State imposes on nonphysician anesthetists; and

(3) Is a graduate of a medical school-based anesthesiologist’s assistant education

program that –

(a) Is accredited by the Committee on Allied Health Education and

Accreditation; and

(b) Includes approximately two years of specialized basic science and clinical

education in anesthesia at a level that builds on a premedical undergraduate science

background.”

Anesthesia Services Policies

The medical staff bylaws or rules and regulations must include criteria for determining

the anesthesia service privileges to be granted to an individual practitioner and a

procedure for applying the criteria to individuals requesting privileges, as required by the

regulations at §482. 22(c)(6) for any type of anesthesia services, including those not

subject to the anesthesia administration requirements at §482.52(a). The hospital’s

governing body must approve the specific anesthesia service privileges for each

practitioner who furnishes anesthesia services, addressing the type of supervision, if any,

required. The privileges granted must be in accordance with State law and hospital

policy. The type and complexity of procedures for which the practitioner may administer

anesthesia must be specified in the privileges granted to the individual practitioner.

Deficiencies related to these requirements should be cited under §482. 22(c)(6).

When a hospital permits operating practitioners to supervise a CRNA administering

anesthesia, the medical staff bylaws or rules and regulations must specify for each

category of operating practitioner, the type and complexity of procedures that category of

practitioner may supervise. However, individual operating practitioners do not need to be

granted specific privileges to supervise a CRNA.

Survey Procedures §482.52(a) and (c)

• Review the qualifications of individuals authorized to administer general

anesthesia, regional anesthesia and monitored anesthesia, including deep

sedation/analgesia to determine if they satisfy the requirements at §482.52(a) and

(c).

• Determine that there is documentation of current licensure and, as applicable,

current certification for all persons administering anesthesia.

• Determine if the state is an “opt-out state” and therefore permits CRNAs to

administer anesthesia without supervision in accordance with 482.52(c).

• Review the hospital’s policies and procedures governing supervision of CRNA’s

and anesthesiologist’s assistants, and determine whether they comply with the

regulatory requirements. and

• Review the qualifications of individuals authorized to furnish other anesthesia

services, to determine if they are consistent with the hospital’s anesthesia service

policies.