CMS SOM App. A, Tag A-1003

§482.52(b) (1) - A pre-anesthesia evaluation completed and documented by an

individual qualified to administer anesthesia, as specified in paragraph (a) of this

section, performed within 48 hours prior to surgery or a procedure requiring

anesthesia services.

Interpretive Guidelines §482.52(b)(1)

A pre-anesthesia evaluation must be performed for each patient who receives general,

regional or monitored anesthesia. While current practice dictates that the patient

receiving moderate sedation be monitored and evaluated before, during, and after the

procedure by trained practitioners, a pre-anesthesia evaluation performed by someone

qualified to administer anesthesia as specified in §482.52(a) is not required because

moderate sedation is not considered to be “anesthesia”, and thus is not subject to that

requirement under this regulation.

The evaluation must be performed by someone qualified to administer anesthesia as

specified in §482.52(a), i.e., only by:

• A qualified anesthesiologist;

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

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

under State law;

• A certified registered nurse anesthetist (CRNA), 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

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

who is immediately available if needed.

Although §482.12 (c)(1)(i) generally provides broad authority to physicians to delegate

tasks to other qualified medical personnel, the more stringent requirements at

§482.52(b)(1) do not permit delegation of the pre-anesthesia evaluation to practitioners

who are not qualified to administer anesthesia.

The pre-anesthesia evaluation must be completed and documented within 48 hours

immediately prior to any inpatient or outpatient surgery or procedure requiring anesthesia

services. The delivery of the first dose of medication(s) for the purpose of inducing

anesthesia, as defined above, marks the end of the 48 hour time frame.

In accordance with current standards of anesthesia care, some of the individual elements

contributing to the pre-anesthesia evaluation may be performed prior to the 48-hour

timeframe. However, under no circumstances may these elements be performed more

than 30 days prior to surgery or a procedure requiring anesthesia services. Review of

these elements must be conducted, and any appropriate updates documented, within the

48-hour timeframe.

The pre-anesthesia evaluation of the patient includes, at a minimum:

Elements that must be performed within the 48-hour timeframe:

• Review of the medical history, including anesthesia, drug and allergy history; and

• Interview, if possible given the patient’s condition, and examination of the

patient.

Elements that must be reviewed and updated as necessary within 48 hours, but which

may also have been performed during or within 30 days prior to the 48-hour time period,

in preparation for the procedure:

• Notation of anesthesia risk according to established standards of practice (e.g.,

ASA classification of risk);

• Identification of potential anesthesia problems, particularly those that may suggest

potential complications or contraindications to the planned procedure (e.g.,

difficult airway, ongoing infection, limited intravascular access);

• Additional pre-anesthesia data or information, if applicable and as required in

accordance with standard practice prior to administering anesthesia (e.g., stress

tests, additional specialist consultation);

• Development of the plan for the patient’s anesthesia care, including the type of

medications for induction, maintenance and post-operative care and discussion

with the patient (or patient’s representative) of the risks and benefits of the

delivery of anesthesia.

Survey Procedures §482.52(b)(1)

• Review a sample of inpatient and outpatient medical records for patients who had

surgery or a procedure requiring administration of anesthesia.

• Determine whether each patient had a pre-anesthesia evaluation by a practitioner

qualified to administer anesthesia.

• Determine whether each patient’s pre-anesthesia evaluation included at least the

elements described above.

• Determine that the pre-anesthesia evaluation was updated, completed and

documented within 48 hours prior to the delivery of the first dose of

medication(s) given for the purpose of inducing anesthesia for the surgery or a

procedure requiring anesthesia services.