How Medical Direction Impacts Anesthesiologist and CRNA Reimbursement

Medical direction is a billing term from the Centers for Medicare & Medicaid Services (CMS) which pertains to an anesthesiologist directing the delivery of anesthesia care from up to four CRNAs. These CRNAs can provide anesthesia care for four different cases concurrently; however, the anesthesiologist must meet seven billing requirements in order for medical direction to be achieved legally. 

Seven Documentation Requirements for Medical Direction

Before we delve further into medical direction, we must first understand the seven requirements for anesthesiologists to adhere to 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
  • Provide post-anesthesia care as indicated

Reimbursement for Medical Direction

In cases where an anesthesiologist is medically directing multiple CRNAs, the QK and QX billing modifiers are used. When these billing modifiers are used, payment is at 50% of the personally performed rate to each provider. When an anesthesiologist medically directs one CRNA, the QY billing modifier is used. Reimbursement for the QY modifier is also at 50% of the personally performed rate to each provider.

Differences Between Medical Direction and Medical Supervision

Medical direction occurs when an anesthesiologist is concurrently supervising and involved in no more than four active anesthesia procedures. When the anesthesiologist cannot perform all seven aforementioned required services under medical direction or is involved in more than four concurrent anesthesia procedures, medical supervision occurs. Under medical supervision, the anesthesiologist bills services under the QD modifier. This means the physician is paid by CMS for only three units with one additional unit being made available if the physician was present on induction. The CRNA still uses the QX modifier and is paid at 50% of the total allowed amount. 

Is Medical Direction or Supervision Required?

Medical direction or supervision is not always required. In some states, called “opt-out” states, CRNAs can legally provide anesthesia care without medical direction or supervision. In many of these cases, payers reimburse at a reduced rate for these services which are billed under the QZ modifier. There are currently 18 states (plus Guam) that have opted out from federal regulations that require physician supervision of CRNAs. 

Should Your Department Operate Under Medical Direction?

Medical direction is still commonly practiced, but it does pose risks. If you are an anesthesiologist and are routinely struggling to meet all seven requirements for compliant medical direction, you should consider medical supervision to avoid compliance concerns. Experts like the ones at CCI Anesthesia can help you determine the safest and most cost efficient plan for your unique situation. We are highly experienced in managing anesthesia services in efficient ways that support any bottom line.

Does your anesthesia department have the right mix of providers working in the right anesthetic locations? For more information on the best anesthesia model for your organization, contact us today at 800.494.3948. Our practice management experts are eager to help you determine the best solution for your facility.