Billing Anesthesia Medical Direction

Medical direction is a common staffing model for anesthesia departments, but is your department in compliance when billing under this model? Although, in essence, medical direction simply means that an anesthesiologist is directing the delivery of anesthesia care from up to four CRNAs, there are actually several stipulations that must be met to ensure compliance. CCI Anesthesia prioritizes compliance initiatives and works hard to ensure all documentation requirements are met if medical direction is used in any of our client facilities.

The Basics of Medical Direction

There are seven requirements in place by the Centers for Medicare and Medicaid Services (CMS) for anesthesiologists to adhere to in this billing rule:

• Perform a pre-anesthetic examination and evaluation;
• Prescribe the anesthesia plan;
• Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence;
• Ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform;
• Monitor the course of anesthesia administration at frequent intervals;
• Remain physically present for all key and critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies; and
• Provide post-anesthesia care as indicated.

Although these requirements may seem routine, several of them pose inherent problems for busy anesthesia departments. We will delve into the most commonly violated requirements and explain why compliance of these requirements can be difficult. Keep in mind that all seven requirements must be met for every case to achieve compliance with CMS.

Participating in Induction and Emergence

Participation in induction and emergence can be one of the more challenging requirements of medical direction for anesthesiologists. In facilities that start multiple cases at the same time each morning, it can be physically impossible for an anesthesiologist to be present for each case he or she is medically directing. Staggered starts can resolve this issue, but it can still be problematic for anesthesiologists to be present for every emergence. Additionally, the requirement for anesthesiologists to be physically present for “the most demanding procedures in the anesthesia plan” can be nearly impossible for anesthesiologists medically directing four CRNAs.

Monitoring the Course of Anesthesia Administration at Frequent Intervals

In the event of a poor outcome, the frequency in which the medically directing anesthesiologist monitored anesthesia administration will be reviewed. When medically directing lengthy cases, anesthesiologists should be able to meet this CMS requirement. However, when short cases are running concurrently, meeting this requirement can be an insurmountable task.

Being Available for Treatment of Emergencies 

Being prepared for emergencies is part of every anesthesia provider’s skillset. Predicting emergencies, however, is often impossible. Even though a CRNA may page the medically directing anesthesiologist in the event of an emergency, it is not always physically possible for the anesthesiologist to be present. Since this rule also requires the anesthesiologist to be present for “all key and critical portions of the procedure,” it can be quite challenging to meet. 

The Bottom Line on Medical Direction

Each of the seven requirements of medical direction have their own set of challenges to meet. However, the most important aspect of medical direction compliance is that all seven requirements are met. If only six requirements or fewer are met, the model is not compliant with CMS. Because it is so difficult to follow all seven rules of medical direction for every single case, medical direction poses risks. If your anesthesiologists are routinely struggling to meet all seven requirements for compliant medical direction, you should consider medical supervision to avoid compliance concerns. The anesthesia management experts at CCI Anesthesia can help you determine the safest and most cost-efficient plan for your unique situation.

Do you have concerns about meeting the seven requirements for medical direction or are you interested in implementing a medical supervision model? Contact us today at 800.494.3948 for more information on determining the best path for your facility.