Medicare Coverage of Chronic Pain Management Services Extended to CRNA

Included in the physician fee schedule final rule update for 2013 is expanded authority for certified registered nurse anesthetists (CRNAs) to provide chronic pain management for Medicare patients  (77 FR 68892 at 69005, Nov. 16, 2012). The services of CRNAs have been reimbursed by Medicare since 1986, although until recent years most of these services have been provided in a surgical setting, under the supervision of an anesthesiologist.

CRNAs are licensed by states and have to meet specific education, training, and other requirements relating to anesthesia services which generally match the requirements established by a national organization for the certification of nurse anesthetists.

By regulation, CRNAs are paid at the same rate as physicians for furnishing such services to Medicare beneficiaries. Payment for services furnished by CRNAs differs from payment for physicians in that payment to CRNAs is made only on an assignment-related basis (§ 414.60) and supervision requirements apply in certain circumstances.

CRNAs have increasingly been providing services outside the surgical setting, such as chronic pain management services. CMS noted in the final rule that “chronic pain management was an evolving field, and we recognized that certain states have determined that the scope of practice for a CRNA should include chronic pain management to meet health care needs of their residents and ensure their health and safety.”

In the Final rule, CMS revised 42 CFR §410.69(b) (77 FR 68892 at 69363) to define the services that CRNAs can provide as ‘‘those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished.’’ In effect, this action results in CRNAs being treated similarly to other advanced practice nurses for Medicare purposes, and is consistent with the Institute of Medicine’s recommendation that Medicare cover services provided by advanced practice nurses to the full extent of their state scope of practice. The intent of the change, according to CMS, is to expand the types of services provided by CRNAs that are reimbursed under Medicare “while  allowing appropriate flexibility to meet the unique needs of each state.”

Some commenters on the proposed rule raised concerns that the change  “expands the scope of practice of CRNAs into the practice of medicine, and that the proposal undermines medical education, the practice of medicine, and the pain medicine specialty by equating nurses with physicians.” CMS replied that the purpose of the change was “not to undermine medical education, the practice of medicine, or the pain medicine specialty, but to establish parity between the scope of the Medicare benefit category for CRNAs and the CRNA authority to practice under state law.”

A story in Anesthesiology News quoted John M. Zerwas, MD, president of the American Society of Anesthesiologists (ASA), as saying the change was a “severely flawed and dangerous” decision on the part of CMS, who added that nurse anesthetists “lack the ability to safely and effectively treat patients with chronic pain using a comprehensive approach, and to appropriately manage the medical conditions contributing to their pain.”