CMS SOM App. L, Tag Q-0062

(2) Before discharge from the ASC, each patient must be evaluated by a physician

or by an anesthetist as defined at §410.69(b) of this chapter, in accordance with

applicable State health and safety laws, standards of practice, and ASC policy, for

proper anesthesia recovery.

Interpretive Guidelines: §416.42(a)(2)

An evaluation of the patient’s recovery from anesthesia, to determine whether the patient

is recovering appropriately, must be completed and documented before the patient is

discharged from the ASC. The American Society of Anesthesiology (ASA) guidelines

do not define moderate or conscious sedation as anesthesia. While current practice

dictates that the patient receiving conscious sedation be monitored and evaluated before,

during, and after the procedure by trained practitioners, a postanesthesia evaluation is not

required.

The evaluation must be completed and documented by a physician or anesthetist, as

defined at 42 CFR 410.69(b), i.e., a certified registered nurse anesthetist (CRNA) or an

anesthesiologist’s assistant. See the discussion at §416.42(b) for more discussion of

CRNA and anesthesiologist’s assistant requirements.

ASCs would be well advised in developing their policies and procedures for

postanesthesia care to consult recognized guidelines. For example, Practice Guidelines

for Postanesthetic Care, Anesthesiology, Vol 96, No 3, March, 2002, provides the

recommendations of the American Society of Anesthesiologists for routine

postanesthesia assessment and monitoring, including monitoring/assessment of:

• Respiratory function, including respiratory rate, airway patency, and oxygen

saturation;

• Cardiovascular function, including pulse rate and blood pressure;

• Mental status;

• Temperature;

• Pain;

• Nausea and vomiting; and

• Postoperative hydration.

Depending on the specific surgery or procedure performed, additional types of

monitoring and assessment may be necessary.

Survey Procedures: §416.42(a)(2)

• Review the ASC’s policies and procedures regarding postanesthesia recovery and

evaluation to determine if they are consistent with the regulatory requirement.

Determine whether the ASC is following its own policy.

• Review a sample of medical records for patients who had surgery or a procedure

requiring anesthesia to determine whether a postanesthesia evaluation was

conducted for each patient.

• Determine whether the evaluation was conducted by a practitioner who is

qualified to administer anesthesia.

• Determine whether the evaluation was performed prior to the patient’s discharge.