Opinion ID: 4023845
Heading Depth: 1
Heading Rank: 3

Heading: The Documentation Issue.

Text: Relator argues that AAKC violated 42 C.F.R. § 415.110(b), which requires the anesthesiologist to “document[] in the patient’s medical record that the conditions set forth in paragraph (a)(1) of this section have been satisfied, specifically documenting that he or she . . . was present during the most demanding procedures, including induction and emergence where applicable.” For each anesthesia procedure, AAKC anesthesiologists and CRNAs complete a two-page Anesthesia Services Form. The CRNA separates the original top page when the patient is transferred to the PACU and submits the carbonless copy second page to AAKC’s billing office. Donegan testified that he and other CRNAs were always instructed to check the “Medical Direction” box at the top of the forms. AAKC anesthesiologists were directed to change this designation if they were supervising more than four cases and thus did not qualify for Medical Direction. The top page of the form remained in the patient’s medical record at MMC. The form includes four lines where the anesthesiologist reflects by initialing that he or she was: (1) “present at induction”; (2) “monitoring at frequent intervals”; (3) “immediately available”; and (4) “present for emergence.” In discovery, Relator 3 Relator’s further contention that the district court abused its discretion by granting AAKC’s motion to strike unidentified portions of Relator’s summary judgment briefs and evidence is without merit. Even if the district court improperly excluded some evidence, which cannot be determined from the record on appeal, the alleged evidentiary error did not “affect[] the substantial rights of the appellant.” Schmidt v. City of Bella Villa, 557 F.3d 564, 569 (8th Cir. 2009) (quotation omitted). -9- sought production of Medical Direction reimbursement claims since July 1, 2002, and the carbonless copies of the Anesthesia Services Form for those claims, but not the original top pages from patient medical records. Out of approximately 13,000 Medical Direction reimbursement claims for general anesthesia services, 724 had an unsigned emergence line on the carbonless copy of the Anesthesia Services Form. Relator moved for partial summary judgment on the 724 claims and appeals the district court denial of that motion. Relator argues that this is conclusive evidence that AAKC failed to comply with Step Three and failed to comply with the record-keeping requirements of 42 C.F.R. § 415.110(b) with respect to those claims. As the district court recognized, the regulation required AAKC to document anesthesiologist presence at emergence “in the patient’s medical record,” not in AAKC’s billing records. When an anesthesiologist visited a patient in the PACU, after the CRNA had sent the carbonless copy of the form to the billing office, one would expect the anesthesiologist to initial the emergence line on the top copy of the form, which became part of the patient’s medical record. Therefore, Relator was not entitled to partial summary judgment on the 724 claims because it made no effort to obtain the top copies of the Anesthesia Services Forms from MMC patient records. AAKC reviewed fifty of those patient files and found that anesthesiologists completed the emergence line in nineteen of them. The district court concluded that Relator at most produced evidence that AAKC “may have negligently submitted 31 of 13,000 Medical Direction claims, which is not an FCA violation.” We agree. “[T]he FCA does not encompass those instances of regulatory noncompliance that are irrelevant to the government’s disbursement decisions.” Ketroser, 729 F.3d at 829 (quotation omitted). The judgment of the district court is affirmed. ______________________________ -10-