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Anesthesia
September 29, 2025
Before the Case Begins: A Closer Look at Preoperative Requirements

Before the Case Begins: A Closer Look at Preoperative Requirements

The notable (and quotable) 19th-century philologist and philosopher Friedrich Nietzsche once observed "He who would learn to fly one day must first learn to stand and walk and run and climb and dance; one cannot fly into flying." What this maxim is meant to convey is this: before the ultimate goal can be achieved, you really need to perform some more basic, preparatory tasks. For most medical specialties, a successful surgical session (the ultimate goal) is preceded by a basic task known as the H&P, which stands for history and physical. In the anesthesia world, we call this pre-surgical preparatory process the pre-anesthesia assessment (PAA).

Before the Case Begins: A Closer Look at Preoperative Requirements

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The PAA is critical in identifying where the patient stands from a clinical perspective prior to surgery so that the anesthesia provider is able to determine (a) whether the patient is able to withstand the anesthesia, (b) the amount and type of anesthetic required, (c) what other modalities may be needed (e.g., invasive lines, postoperative pain blocks, preoperative sedation), and (d) what preemptive nausea-mitigation factors need to be deployed, among other determinations.

ASA Guidelines

And, yes, there are guidelines for performing the PAA. On October 14, 1987, the American Society of Anesthesiologists (ASA), through its House of Delegates, approved and published a set of standards relating to the PAA. The document, titled “Basic Standards for Pre-anesthesia Care Committee of Origin: Standards and Practice Parameters” (later affirmed on December 13, 2020), sets forth principles that should apply to all patients who receive anesthesia care.

According to the ASA guidelines, an anesthesia provider is responsible for determining the medical status of the patient and developing a plan of anesthesia care. The provider, before the delivery of anesthesia care, is specifically responsible for:

  1. Reviewing the available medical record.
  2. Interviewing and performing a focused examination of the patient to:
    1. Discuss the medical history, including previous anesthetic experiences and medical therapy.
    2. Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management.
  3. Ordering and reviewing pertinent available tests and consultations as necessary for the delivery of anesthesia care.
  4. Ordering appropriate preoperative medications.
  5. Ensuring that consent has been obtained for the anesthesia care.
  6. Documenting in the chart that the above has been performed

Under exceptional circumstances, these standards may be modified, according to the ASA. When this is the case, such circumstances should be documented in the patient’s record.

While not codified into law or federal regulation, position statements by the leading society of a particular medical specialty are not altogether discounted before a trier of fact, such as a court or administrative law judge. In other words, what the ASA says about the duties of anesthesia providers concerning the PAA should be carefully considered by those engaged in the practice of anesthesia.

Medicare Guidelines

The Centers for Medicare and Medicaid Services (CMS) has published a set of guidelines for surveying organizations, such as the Joint Commission, to follow in order to ensure that hospitals that participate with Medicare are in compliance with accepted clinical standards. These conditions of participation (CoPs) are set forth in the Medicare State Operations Manual (MSOM). To help provide further elucidation on these expected standards, the MSOM incorporates several explanatory sections within the CoPs known as the interpretive guidelines (IGs). The IGs relating to Medicare’s PAA expectations point out the following:

Duty to Perform. A PAA must be performed for each patient who receives general, regional or monitored anesthesia. CMS makes an exception only under exigent circumstances, where there is no time to perform a full exam and evaluation prior to surgery. However, the provider should document in the medical record such circumstances and update the PAA when possible.

Limited Personnel. The PAA may only be performed by someone qualified to administer anesthesia, i.e., the following: (a) a qualified anesthesiologist, (b) a non-anesthesiologist doctor of medicine or osteopathy, (c) a dentist, oral surgeon or podiatrist who is qualified to administer anesthesia under state law, (d) a CRNA who, unless exempted, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed, or (e) an anesthesiologist’s assistant (AA) who is under the supervision of an anesthesiologist who is immediately available if needed.

Timing of Service. The PAA must be completed and documented within 48 hours immediately prior to any procedure requiring anesthesia services. In accordance with current standards of anesthesia care, some of the individual elements contributing to the PAA may be performed prior to the 48-hour timeframe. However, under no circumstances may these elements be performed more than 30 days prior to surgical/anesthesia service.

Service Components. Elements that must be performed within the 48-hour timeframe are as follows:

  • Review of the medical history, including anesthesia, drug and allergy history
  • Interview, if possible given the patient’s condition, and examination of the patient

Elements that must be reviewed and updated as necessary within 48 hours, but which may also have been performed during or within 30 days prior to the 48-hour time period, in preparation for the procedure include the following:

  • Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk)
  • Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access)
  • Additional pre-anesthesia data or information, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation)
  • Development of the plan for anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient’s representative) of the risks and benefits of the delivery of anesthesia

The main takeaway of all this is that hospitals are being tasked by Medicare-approved surveying organizations to look at your records to determine if you are meeting the above criteria. Accordingly, anesthesia providers are encouraged to refamiliarize themselves with these Medicare, as well as ASA, expectations in the context of the PAA.