It is important for all anesthesia organizations to understand billing for medical direction. The anesthesiologist medically directs the CRNA or AA when he or she directs one, two, three or four concurrent cases performed by a CRNA or AA. The anesthesiologist may not medically direct more than four concurrent cases.

The Centers for Medicare and Medicaid Services (CMS) seven requirements expect the attending anesthesiologist to perform and document the following:

Perform a pre-anesthesia examination and evaluation

The anesthesiologist must perform and document a pre-anesthesia evaluation and exam prior to surgery or any procedure that requires anesthesia. The anesthesiologist must document this on the anesthesia record. The evaluation must document the patient?s condition such as age, mental status or any physical comorbidities that mays affect the anesthetic. This should include a review of the medical record. The anesthesiologist must also assign an ASA Physical status on the record.

Prescribe the anesthesia plan

According to the pre-anesthesia evaluation the anesthesiologist will determine a plan for the procedure. This is a key feature of Billing for Medical Direction. The anesthesia plan is discussed, prescribed and documented with the anesthesiologist medically directing the case when the evaluation was performed by a nurse practitioner or CRNA. Anesthesia providers may change the plan at any time during the procedure if medically necessary. Changes are documented in the anesthesia record.

Personally, participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence

The anesthesiologist must document presence and availability throughout the procedure including, if applicable induction and emergence. The signatures must occur at the time of these events. Pre-signing of the record is not acceptable. A MAC or regional anesthetic has no period of induction or emergence. This is one of the steps most likely overlooked when billing for medical direction.

Qualified individual must perform anesthesia

Ensure that any procedures in the anesthesia plan that the physician does not perform are performed by a qualified individual.

All individuals involved in the care of the patient must have current licensure and training certification on record with the organization. An organization may have to refund billing performed by an unqualified provider.

Monitor the course of anesthesia administration at frequent intervals

CMS has not specifically defined the frequency to monitor and document in the record. Induction and emergence documentation is sufficient for cases of one hour or less. For longer cases, many organizations document every 60-90 minutes. This would apply to general or MAC cases.




Must remain physically present 

The anesthesiologist must remain physically present and available for immediate diagnosis and treatment of emergencies  The anesthesiologist must document their availability in case of emergencies. They must remain within the area to assist with all emergencies. If they are unable, they may not bill medical direction.

Provides indicated post-anesthesia care

The anesthesiologist must be available to provide all necessary post-anesthesia care in the recovery room.  The provider completes and documents a post-anesthesia evaluation within 48 hrs. of any surgery.

Other Key Concepts

To satisfy Billing for Medical Direction, the anesthesiologist may address emergencies of short duration in the immediate area or administer an epidural or caudal anesthetic to ease labor pain or perform periodic monitoring of an obstetrical patient.

The anesthesiologist may receive patients entering the operating suite for the next surgery while directing concurrent anesthesia procedures or checking  or discharging patients in the recovery room or dealing with scheduling matters.

If the anesthesiologist leaves the area or is otherwise not available to respond his work becomes supervisory in nature. They may not bill as medically directed.

In most situations, anesthesia providers do a great job of following these guidelines, but we continue to see missed presence at induction and emergence.  It is everyone?s responsibility to make sure this takes place.  Physicians have to make an effort to be present and CRNAs can help by notifying their coverage of the need for presence at those critical moments.