Medical Direction, Medical Supervision, and Other Things to Know for Anesthesia Care Team Billing

As Anesthesia care teams become more prevalent in today’s operating suites, knowing how to bill for the services of each care team member becomes essential. That means learning the difference between medical direction and medical supervision, understanding when CRNAs can be billed alone and when they can’t, and what modifiers to use for all these options.

Here’s a primer to get you started.

Medical Direction

Medical direction occurs when an anesthesiologist is involved in up to four concurrent anesthesia procedures with a qualified nonphysician anesthetist (usually a CRNA or an anesthesiologist’s assistant, or AA). Based on guidelines from the Centers for Medicare and Medicaid Services (CMS), in order to be considered medical direction the anesthesiologist must do the following in all cases being directed:

Perform a pre-anesthetic examination and evaluation;
Prescribe the anesthesia plan;
Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence;
Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual;
Monitor the course of anesthesia administration at frequent intervals;
Remain physically present and available for immediate diagnosis and treatment of emergencies;
Provide indicated post-anesthesia care.

As well, physicians who are concurrently furnishing services under medical direction cannot ordinarily be involved in furnishing additional services to other patients, except in the following situations:

Addressing an emergency of short duration in the immediate area,
Administering an epidural or caudal anesthetic to ease labor pain,
Periodic (rather than continuous) monitoring of an obstetrical patient,
Receiving patients entering the operating suite for the next surgery,
Checking or discharging patients in the recovery room,
Handling scheduling matters.

Under medical direction, the anesthesia service is billed under the anesthesiologist with the QY (1 case) or QK (2-4 cases) modifier. In these cases, Medicare reimburses the physician at 50% of the total allowed amount. The same anesthesia service is billed under the CRNA/AA using the QX modifier and also is paid at 50% of the total.

Medical Supervision

The concurrent work of an anesthesiologist is considered medical supervision if an anesthesiologist is involved in more than four concurrent anesthesia procedures with a qualified nonphysician anesthetist, or when the anesthesiologist cannot perform all seven required services under medical direction regardless of the number of concurrent anesthesia procedures.

Under medical supervision, the anesthesia service is billed under the anesthesiologist with the QD modifier, but the physician is paid (under Medicare) for only three units (plus one additional unit if documentation shows the physician was present on induction). The same anesthesia service is still billed under the CRNA/AA using the QX modifier and is still paid at 50% of the total allowed amount under Medicare.

CRNA without Direction or Supervision

Finally, based on an exemption allowed by CMS, CRNAs in some states can provide anesthesia services without medical direction or supervision.

Effective November 13, 2001, CMS established an exemption for Certified Registered Nurse Anesthetists (CRNAs) from the physician supervision requirement. Currently, seventeen States have chosen to opt-out of the CRNA physician supervision regulation, including California, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana, Colorado, and Kentucky.

In those cases, anesthesia services are billed under the CRNA’s individual NPI, and the CRNA receives payment of 80% of the total allowed amount after the deductible is met.

As well, in some rare situations, it is medically necessary for both the CRNA and the anesthesiologist to be completely and fully involved during a procedure. In this case, the physician would report using the “AA” modifier and the CRNA would use “QZ,” or the modifier for a nonmedically directed case. Each provider also would receive the full payment they are allowed.

Care Team Overview

For an overview of how anesthesia care team members bill for services, check out the chart below:

	Medical Direction	Medical Direction	Medical Supervision	CRNA/AA w/Phys	CRNA and Phys Both Provide Full Care	CRNA Alone*
Modifier	QY	QK	AD	QX	AA – Phys QZ – CRNA	NONE
Number of Cases	1	2, 3, 4	5+ (or fewer when physician can no longer provide all services required for direction – see above)	1	1	1
Clinician	Physician	Physician	Physician	CRNA/AA	Physician & CRNA	CRNA
Medicare Payment	50% of total allowed amount	50% of total allowed amount	Conversion factor x3 (or 4 if present on induction)	50% of total allowed amount	100% – Phys 100% – CRNA of total allowed amount	100% of total allowed amount

*Varies by state based on exemptions. Visit the American Association of Nurse Anesthetists website for a list of states where CRNAs do not need medical direction or supervision.

For more information about billing for care team members,