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CRNA Exemption to the Fee Schedule

Under the provisions at 42 CFR 412.113(c), a rural hospital or Critical Access Hospital (CAH) may qualify to receive anesthesiology services furnished by employed or contracted nonphysician anesthetists (Certified Registered Nurse Anesthetist(CRNA)/Anesthesiology Assistant(AA)) at cost versus the fee schedule on a calendar year basis. It is the provider's responsibility to request and supply all supporting documentation to determine if the qualifications listed at 42 CFR 412.113(c) are met. Documentation sent to the contractor must be postmarked by December 31st.

Qualifications per 42 CFR 412.113(c):

  • To be geographically located in a rural area under 42 CFR 412.62(f).*
  • The hospital/CAH must employ or contract with a qualified nonphysician anesthetist(s) to perform services in that hospital/CAH, but the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year. These hours represent total hours at the hospital (not just in surgery) and include time spent in furnishing anesthesia services to patients and general services to the hospital (Federal Register/Vol. 57, No. 148, Friday July 31, 1992).
  • The volume of inpatient and outpatient surgical procedures (see the surgical section of the CPT manual for a list of surgical procedures) requiring anesthesia services did not exceed 800 procedures. (Federal Register/Vol.67, No.148/Thursday, August 1, 2002).
  • Each qualified nonphysician anesthetist under contract or employed by the hospital or CAH has agreed in writing not to bill on a reasonable charge basis for his/her patient care to Medicare beneficiaries.

    * Some CAH facilities may be geographically reassigned to urban regions under the CBSA designation. In those instances where special exemption has been granted by the CMS Regional Office for the hospital to retain their CAH status in the urban geographical region, a copy of the CMS exemption letter should be sent along with the supporting documentation.

Examples of supporting documentation may include the following:

  • Copies of CRNA/AA contracts. If the CRNA/AA is employed by the hospital/CAH, the CRNA exemption request submitted by the facility should indicate that the CRNA/AA is an employee of the hospital/CAH.
  • Supporting documentation to define the total number of hours spent at the facility, whether performing anesthesia or other services.
  • A signed statement by each CRNA/AA agreeing that he/she will not bill on a fee schedule basis for patient care services. This statement must include the current review period.
  • A surgical log with dates of procedures that were performed between January 1st and September 30th of the current year. The log must contain:
    • Surgery Date
    • Patient Name
    • Surgeon Name
    • Anesthetists' Name (CRNA/AA)
    • Type of Anesthesia
    • Type of Surgical Procedure

This information may be submitted to the contractor by means of electronic media (such as Compact Disc). Due to the presence of PHI/PII, data should be password protected and communicated to the WPS Reimbursement Supervisor. This provides a level of protection not available with paper copies.

If WPS notifies your hospital that it qualifies for reasonable cost reimbursement for nonphysician anesthetist services, please be aware your hospital must continue to meet all the requirements in 42 CFR 412.113(c) for the year in which reasonable cost reimbursement has been approved. For example, your hospital submits information for the period January 1, 2011 to September 30, 2011 and WPS, based on our review of that information, notifies the hospital it qualifies for cost reimbursement in 2012. If we audit nonphysician anesthetist reimbursement at final settlement of the hospital's cost report that begins in 2012 and conclude the hospital has not met the 412.113(c) requirements during the cost reporting period, we will disallow all cost reimbursement for nonphysician anesthetist services in that period.

For questions, please contact the WPS Reimbursement Supervisor or the WPS Audit Supervisor assigned to your facility.