As the role of physician extenders in anesthesiology continues to grow, it is important that supervising physicians closely adhere to the Centers for Medicare & Medicaid Services (CMS) rules regarding medical direction in order to avoid reimbursement issues and compliance headaches.

“Providers should be aware of the compliance risks associated with medical direction,” said Lynn Cook, compliance program director for anesthesia with McKesson Business Performance Services (McKesson). “Physicians need to make sure they’re not only following the guidelines, but also documenting all the necessary criteria required to meet medical direction. They need to fully understand the regulations and limitations regarding their care team members.”

The use of certified registered nurse anesthetists (CRNA) and anesthesiologist assistants (AAs) has increased as the healthcare system grapples with a growing population of aging patients and the expansion of outpatient surgeries. CRNAs administer more than 65% of all anesthetics annually and are the sole providers of anesthetics in approximately one-third of all hospitals and 85% of rural hospitals.1

Groups should ask the following question when considering the use of CRNAs and AAs within their groups. Can the CRNA perform services without the supervision of an anesthesiologist? In 17 states, the so-called Opt-Out states, CRNAs can work without the direct supervision of physicians.2 The AA must always be medically directed and is limited in areas where the CRNA is not.

Along with the regulations surrounding CRNAS and AAs, there are additional regulations and documentation requirements associated with residents and student nurse anesthetists. Providers should be sure they fully understand these rules.

The seven steps

CMS medical direction guidelines3 allow anesthesiologists to concurrently direct up to four qualified individuals simultaneously, including CRNAs and/or AAs, with additional requirements for medical residents and student CRNAs, Cook said. Physicians must adhere to the following seven specific steps. Otherwise, medical direction does not occur:

  • Perform a pre-anesthetic exam and evaluation.
  • Prescribe the anesthesia plan.
  • Personally participate in the most demanding aspect of the anesthesia plan including, if applicable, induction and emergence.
  • Ensure that any procedures in the anesthetic that he or she does not perform are performed by a qualified individual as defined in operating instructions.
  • 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.

Assuming an anesthesiologist is medically directing up to four cases, they can provide the following services without undermining the medical direction designation:

  • Address an emergency of short duration in the immediate area.
  • Administer an epidural or caudal anesthetic to ease labor pain.
  • Periodic, rather than continuous, monitoring of an obstetrical patient.
  • Check or discharge patients in the recovery room.
  • Handle scheduling matters.

Supervisory cases

Mary Jo Gross, McKesson’s National Coding Manager for anesthesia, said a case is no longer considered to be under medical direction and becomes supervisory in nature if the anesthesiologist engages in any of the following activities:

  • Leaves the immediate area of the operating suite for other than short durations;
  • Devotes extensive time to an emergency case
  • Is otherwise not available to respond to the immediate needs of the surgical patients.4

When a case becomes supervisory – due to the physician directing more than four cases or because the medical direction rules are not met – reimbursement can be significantly diminished, Gross said.

According to CMS guidelines, only three base units per procedure may be allowed by the Medicare carrier, with an additional time unit recognized if the anesthesiologist can document present at induction.

Cook said a common compliance issue involves relief time in a care team model. She said it is important for the relieving clinician to fully understand the number and nature of the cases they’re directing. An anesthesiologist cannot relieve a CRNA that he or she is medically directing if the physician is currently directing other cases. Also, the relieving physician cannot both personally perform his own case and take responsibility for medical direction and oversight involving other cases. It is always most appropriate to follow best practices: An MDA covers for an MDA, a CRNA covers for a CRNA, An AA covers for an AA and a resident covers for a resident.

Full documentation essential

Cook said that as anesthesiology records increasingly shift from paper to electronic health records, clinicians need to be sure they understand how their documentation is being presented in these records and that if presented for audit all documentation can be clearly identified.

“You’ve got to be complete, consistent, accurate and appropriate in your documentation,” she said.

1 "Advanced Practice Nursing: A New Age in Health Care (PDF, 740 KB),” Backgrounder, American Nurses Association.
2Anesthesia Supervision, CMS Spotlight, Jan. 21, 2015.
3Medicare Claim Processing Manual (PDF, 70 KB), Chapter 12 – Physicians/Non-physician practitioners, p. 121.
4 Ibid at page 123.


About the author

McKesson Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.