II

103D CONGRESS

2D SESSION S. 2310

To direct the Secretary of Health and Human Services to revise existing

regulations concerning the conditions of payment under part B of the

medicare program relating to anesthesia services furnished by certified

registered nurse anesthetists, and for other purposes.

IN THE SENATE OF THE UNITED STATES

JULY 21 (legislative day, JULY 20), 1994

Mr. CONRAD (for himself and Mr. INOUYE) introduced the following bill;

which was read twice and referred to the Committee on Finance

A BILL

To direct the Secretary of Health and Human Services to

revise existing regulations concerning the conditions of

payment under part B of the medicare program relating

to anesthesia services furnished by certified registered

nurse anesthetists, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. REVISION OF CONDITIONS OF PAYMENT RE2 LATING TO ANESTHESIA SERVICES FUR3 NISHED BY CERTIFIED REGISTERED NURSE

4 ANESTHETISTS.

5 (a) PROMULGATION OF REVISED REGULATIONS.—

6 The Secretary of Health and Human Services shall revise

7 any regulations describing the conditions under which pay8 ment may be made for anesthesia services under the medi9 care program so that—

10 (1) payment may be made for anesthesia serv11 ices furnished in a hospital or an ambulatory sur12 gical center by a certified registered nurse anes13 thetist who is permitted to administer anesthesia

14 under the law of the State in which the service is

15 furnished; and

16 (2) the conditions under which payment may be

17 made for a physician service consisting of the medi18 cal direction or medical supervision of a certified

19 registered nurse anesthetist—

20 (A) shall not restrict such nurse anes21 thetists working with anesthesiologists from

22 performing all the components of the anesthesia

23 service that such nurse anesthetists are legally

24 authorized to perform in the State in which the

25 service is furnished; and
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1 (B) shall prevent fraud and abuse in pay2 ment for the services by requiring that the phy3 sician providing medical direction or medical

4 supervision must be physically present in the

5 facility where the certified registered nurse an6 esthetist’s services are performed and must be

7 available in a timely manner for consultation or

8 assistance if indicated.

9 (b) CONSULTATION REQUIRED.—The Secretary shall

10 revise the regulations referred to in subsection (a)(2) only

11 after consultation with representatives from professional

12 associations of certified registered nurse anesthetists and

13 anesthesiologists.

14 (c) EFFECTIVE DATES.—

15 (1) IN GENERAL.—The revisions to the regula16 tions referred to in subsection (a) shall apply to an17 esthesia services furnished on or after January 1,

18 1995.

19 (2) TERMINATION OF REGULATIONS ON MEDI20 CAL DIRECTION OR SUPERVISION.—The revised reg21 ulations referred to in subsection (a)(2) shall not

22 apply to services furnished on or after January 1,

23 1998.
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1 SEC. 2. ENSURING PAYMENT FOR PHYSICIAN AND CER2 TIFIED REGISTERED NURSE ANESTHETIST

3 FOR JOINTLY FURNISHED ANESTHESIA SERV4 ICES.

5 (a) PAYMENT FOR JOINTLY FURNISHED SINGLE

6 CASE.—

7 (1) PAYMENT TO PHYSICIAN.—Section

8 1848(a)(4) of the Social Security Act (42 U.S.C.

9 1395w–4(a)(4)), as added by section 13516(a) of

10 the Omnibus Budget Reconciliation Act of 1993

11 (hereafter referred to as ‘‘OBRA–1993’’), is amend12 ed by adding at the end the following new subpara13 graph:

14 ‘‘(C) PAYMENT FOR SINGLE CASE.—

15 ‘‘(i) IN GENERAL.—Notwithstanding

16 section 1862(a)(1)(A), if—

17 ‘‘(I) physicians’ services consist18 ing of the furnishing of anesthesia

19 services for a single case are furnished

20 jointly with a certified registered

21 nurse anesthetist, and

22 ‘‘(II) the carrier determines that

23 the use of both the physician and the

24 certified registered nurse anesthetist

25 was not medically necessary,
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1 the fee schedule amount for the physicians’

2 services shall be equal to the applicable

3 percentage of the fee schedule amount ap4 plicable under this section for anesthesia

5 services personally performed by the physi6 cian alone (determined without regard to

7 this subparagraph).

8 ‘‘(ii) APPLICABLE PERCENTAGE.—For

9 purposes of clause (i), the applicable per10 centage is the percentage (as determined

11 in a manner to be provided by the Sec12 retary) of the jointly furnished anesthesia

13 services which were actually furnished by

14 the physician.

15 ‘‘(iii) LIMITATION.—The Secretary

16 shall establish procedures that ensure that

17 the sum of the fee schedule amounts deter18 mined under clause (i) and section

19 1833(l)(4)(B)(iv) for a jointly furnished

20 anesthesia service shall not exceed 100

21 percent of the fee schedule amount applica22 ble under this section for anesthesia serv23 ices personally performed by the physician

24 alone (determined without regard to this

25 subparagraph).’’.
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1 (2) PAYMENT FOR CRNA.—Section

2 1833(l)(4)(B) of such Act (42 U.S.C.

3 13951(l)(4)(B)), as added by section 13516(b) of

4 OBRA–1993, is amended by adding at the end the

5 following new clause:

6 ‘‘(iv)(I) Notwithstanding section 1862(a)(1)(A), if—

7 ‘‘(aa) certified registered nurse anesthetist serv8 ices consisting of the furnishing of anesthesia serv9 ices for a single case are furnished jointly with a

10 physician, and

11 ‘‘(bb) the carrier determines that the use of

12 both the certified registered nurse anesthetist physi13 cian and the physician was not medically necessary,

14 the fee schedule amount for the services furnished by the

15 certified registered nurse anesthetist shall be equal to the

16 applicable percentage of the fee schedule amount applica17 ble under section 1848 for anesthesia services personally

18 performed by the physician alone (determined without re19 gard to section 1848(a)(4)(C)).

20 ‘‘(II) For purposes of subclause (I), the applicable

21 percentage is the percentage (as determined in a manner

22 to be provided by the Secretary) of the jointly furnished

23 anesthesia services which were actually furnished by the

24 certified registered nurse anesthetist.
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1 ‘‘(III) The Secretary shall determine the fee schedule

2 amount under subclause (I) in accordance with the proce3 dures established by the Secretary under section

4 1848(a)(4)(C)(iii).’’.

5 (3) EFFECTIVE DATE.—The amendments made

6 by paragraphs (1) and (2) shall apply to services

7 furnished on or after January 1, 1995.

8 (b) UNIFORM TREATMENT OF ALL MULTIPLE CON9 CURRENT CASES.—

10 (1) IN GENERAL.—Section 1848(a)(4) of such

11 Act (42 U.S.C. 1395w–4(a)(4)) and section

12 1842(b)(13) of such Act (42 U.S.C. 1395u(b)(13)),

13 as amended by section 13516(a) of OBRA–1993,

14 are each amended—

15 (A) by striking ‘‘two, three, or four’’ each

16 place it appears and inserting ‘‘two or more’’;

17 and

18 (B) by inserting ‘‘or medical supervision’’

19 after ‘‘medical direction’’ each place it appears.

20 (2) EFFECTIVE DATE.—The amendments made

21 by paragraph (1) shall apply to services furnished on

22 or after January 1, 1998.

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