Re "Ask Caryl" (September, page 30). The table of ASC Medicare-approved laparoscopy procedures lists CPT 47560 (laparoscopy with cholangiography) and CPT 47561 (laparoscopy with cholangiography and biopsy). The listing of these two procedures as approved and cholecystectomy's not being approved mystifies me. As a practicing surgeon for 35 years, it would be very uncommon for an individual to do a laparoscopy and cholangiography unless he were to perform a cholecystectomy at the same time. If Medicare approves cholangiography with laparoscopy, it would seem strange that it does not permit laparoscopic cholecystectomy. When you perform a cholangiography, usually you will use the cystic duct and occlude the distal cystic duct to insert the catheter.

Raymond Dieter, MD
The Center for Surgery
Naperville, Ill.

FASA replies:
In response to the 1998 proposed rule, FASA and others recommended that the CPT codes for laparoscopy surgical cholecystectomies (CPT 47562, 47563 and 47564) be added to the ASC list. Explaining its reason for not adding these procedures, CMS indicated that while these procedures may be appropriately performed in an ASC for non-Medicare patients, an overnight stay often would be required for Medicare patients. This analysis is troubling for several reasons. It seems entirely inappropriate to deny one Medicare beneficiary for whom the ASC is an appropriate setting access to an ASC because another patient might need an overnight stay. If the procedures were only being performed on inpatients, the argument would have validity, but Medicare volume data shows that these procedures were being performed on an outpatient basis 50 percent (CPT 47562), 46 percent (CPT 47563) and 25 percent (CT 47564) of the time. Given this data, we believe it is an error to argue that these are inpatient procedures.

The Quest for Safe Office Anesthesia
Re: "Controversial Study Indicts Office Surgery Safety" (October, page 8). One must consider the issue of potential for bias in this study. From the perspective of ASCs, any case performed in an office is an operating loss to the ASC. Also, remember, that there is a very strong financial incentive to present offices as inherently dangerous and ASCs as unquestionably safer. This leads to the (unreasonable) political position that it is acceptable to have abdominoplasty patients die from pulmonary embolic phenomena when operated on in an ASC or hospital environment but not when the identical surgery is performed in an office setting. No one has a greater stake in the safety of office anesthesia than those of us who practice exclusively in this setting. If, as you report, 84 percent of the physicians involved in adverse office events were board-certified and held active hospital OR privileges, then the gold standard of safety promulgated by the plastic surgical society must indeed be suspect, and more seriously, that Dr. Vila's assertion that "problems arise when doctors perform operations outside their expertise" is untenable on the face of the facts presented.

Barry L. Friedberg, MD
Corona del Mar, Calif.
writeMail("[email protected]")

AAs Lack Experience, Education
Re: "Beating the Anesthesia Provider Shortage" (September, page 84). I am a CRNA. I know AAs are here to stay. Still, this makes as much sense as training two-year surgical assistants and letting several of them perform operations under the direction of one surgeon. Maybe not a bad idea. The surgeon could sit in a lounge drinking coffee and if one of the surgeons assistants needed help he could do that, just like an anesthesiologist does with AAs. Maybe you could take that suggestion to the AMA? Time will demonstrate what an error in judgment AAs are. Just as the AMA is critical of RNs who do not have a BSN, AAs will one day share statistical morbidity and mortality related to their education and experience before entering practice. The dead and wounded will serve as a lesson learned.

Name withheld upon request As a Master's prepared CRNA, my concern is that AAs are not required to have prior medical training as do MDAs and CRNAs. An AA who is not closely supervised by an anesthesiologist is a recipe for disaster in the operating room. As an independent-practice CRNA who has worked in all settings, I have found the biggest impediments to the advancement of anesthesia care are by far anesthesiologists and CRNAs who do not keep learning. What's needed to address the shortage of anesthesia providers is to open more CRNA Masters programs using higher-quality BSN Nurses rather than Whatever AAs.

Mark A. Williams, CRNA, MS, MGA, FAAPM
Contract Obstetrical CRNA
Free Lance Anesthesia
writeMail("[email protected]")