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SPA Newsletter

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SPA Governmental Affairs Committee Report

There was a brief discussion regarding the Policy Statement on Pediatric Anesthesia recently adopted by California Society of Anesthesiologists. This policy parallels the concepts set forth previously in the "Guidelines for the Pediatric Perioperative Environment" and the ASA brochure on Pediatric Anesthesia. The policy emphasizes the responsibility of the medical staff to determine the appropriate scope of pediatric perioperative care for a given facility, including the identification of patients at increased risk who would require more than routine levels of care. It is hoped that more State component Societies will follow suit and adopt similar proactive policies. Along these lines, ASA representatives to the ambulatory surgery center accrediting agencies AAAHC and AAAASF, Jeff Apfelbaum and Beverly Philip have been successful in introducing a statement into the manuals of these organizations, requiring a written policy defining the appropriate scope of pediatric care for the facility. This was the result of discussions that took place at last year's ASA meeting in Orlando.

The majority of the meeting was devoted to a presentation by Dr. Przybylo, who is a member of the ASA Committee on Economics and has had significant impact through this committee on developing new pediatric specific surgical codes for the AMA's CPT book. Jay explained to us the process by which new codes are developed and approved, and then given a value "relative" to values assigned to anesthetic services for other procedures. The most interesting part of the discussion focused on moving away from "modifiers" to distinguish the increased risk and therefore work value inherent in providing anesthesia for small infants, as we have done in the past, and instead to build the increased value into a completely unique CTP code for the surgical procedure when the patient is under a certain age. The use of "modifiers" (appended to the CPT code to signify a special circumstance or service) has become somewhat anachronistic and irrelevant, as Medicare and many health insurance plans have refused to recognize and pay additional amounts. The use of a different and unique CPT code when the patient is very young, addresses the increased service provided more unambiguously. The 2002 ASA Relative Value Guide included three new codes which increased value based upon patient age: procedures on the larynx and trachea in children less than 1 yr of age increased from 6 units to 10 units, hernia repairs under 1 yr of age increased from 4 units to 5 units, and hernia repairs in infants less than 37 wks gestational age at birth and less than 50 wks gestational age at time of surgery increased from 4 units to 6 units Several more new codes for surgeries in infants with increased values are in the approval process. Jay also discussed this process, which is very complex and takes several years for a new code to become accepted by 3rd party payers.

Committee members found Dr. Przybylo's presentation fascinating, and there was general consensus that this information would be of value to SPA members. It was noted that many pediatric anesthesiologists are not well acquainted with billing practices, CPT codes, and other economic advocacy issues, perhaps because many practice within a large academic or children's hospital setting and are not involved in coding and billing activities. The suggestion was made that Jay might write an article for the Newsletter on this subject and that it be included in educational programs.

At the end of the meeting there was a brief discussion about the inadequacy of material resources because of limitations by manufacturers. Several reports from around the country suggest that manufactures intend to cease production of traditional IV catheters and make only IV catheters with engineered safety devices. It is generally agreed that, in certain circumstances, the lack of traditional IV catheters is detrimental to optimal patient care and safety. Drs Cote, Przybylo and others at Memorial Children's Hospital in Chicago published a study, in the Feb, 2003 issue of Anesthesia & Analgesia, supporting the importance of retaining stocks of traditional IV catheters for patient and staff safety considerations. Several years ago, the California Society of Anesthesiologists persuaded the California Occupational Safety and Health Administration to notify California hospitals that they had a duty, while promoting the new, engineered safety device sharps devices, to retain traditional supplies or face potential liability for adverse outcomes. This letter was distributed to California health care facilities and is posted on the California Society of Anesthesiologists web site (csahq.org) for anesthesiologists to use in making this argument to administrators. The regulations that mandate the implementation of these new devices, allow for exemptions to their use, based upon the medical judgment of the practitioner performing the procedure. It is clear that we should remain vigilant on this issue and continue to insist on having access to the basic sharps when we need them to provide the best care for our patients. We may need to make the same argument to manufacturers that we have made to the facilities where we work, and the OSHA regulators (usually MDs who understand our concerns) will be important in helping us.

Another item involving product manufacturers has to do with a desire (mine and others) to have a Laryngeal Mask Airway smaller than the currently available size 1, for use in very small infants and neonates. There are many instances where a general anesthetic in these patients would be facilitated by having a smaller LMA. I have begun a dialogue with officials at the LMA Company and they seem willing to entertain such a request if the pediatric anesthesia community voiced the need. I hope this is something that SPA could support.

Respectfully submitted,

Mark Singleton, MD

Table of Contents

• President's Message
• Editor's Corner
• Joint Meeting of SPA and JSPA
• Out and About the ASA
  • Pediatric Clinical Forum at ASA
  • Pediatric Panel: Pediatric Pain Management
  • Controversies in Malignant Hyperthermia, Cases from the MH Hotline
  • American Academy of Pediatrics Secion on Anesthesiology Breakfast Panel
  • Tuesday Morning general Pediatric Anesthesia Poster Discussions and Poster Sessions of General Pediatric and Pediatric Cardiac Anesthesia
• American Academy of Pediatrics Section on Anesthesia and Pain Medicine Update
• Fellows Corner
  • Non-ACGME Approved Fellowship Training Programs for Pediatric Anesthesia
• WEB ONLY
  • SPA Governmental Affairs Committee Report
  • Literature Review: Hyperkalemia and Pyloric Stenosis
  • Literature Review: Early Exposure to Common Anesthetic Agents Causes Widespread Neurodegeneration in the Developing Rat Brain and Persistent Learning Deficits
  • Laryngeal mask insertion in children: a rational approach
  • Remifentanil Infusion for Cleft Palate Surgery in Young Infants
  • Tuesday Morning General Pediatric Anesthesia Poster Discussions and Poster Sessions of General Pediatric and Pediatric Cardiac Anesthesia

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