Document required for Anesthesia services

Medical Direction

Medical direction occurs when an anesthesiologist is involved in two, three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist. Payment will be determined for  the physician’s medical direction service of the allowable charge for the physician personally performing the
anesthesia services. For each anesthesia procedure, the anesthesiologist must provide the following seven services and record each in the patient’s anesthesia record:

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


If the above services are not performed by the anesthesiologist, the service is not considered medical direction. The anesthesiologist must document in the patient’s medical record that he or she performed the pre-anesthesia examination and evaluation. The record should also document that the anesthesiologist provided post-anesthesia and whether the anesthesiologist was present during some portion of the anesthesia monitoring or during the most demanding procedures, including induction
and emergence, where applicable.

When the anesthesiologist does not fulfill all of the “medical direction” requirements listed above, the concurrent anesthesia services are considered medical supervision services, not medical direction services.

• When an anesthesiologist is supervising more than four concurrent cases, the service should be filed as follows: anesthesiologist – “AD” and CRNA – “QX”

• When a CRNA personally performed the services without medical direction or supervision, as described above, the service should be filed as follows: CRNA – “QZ”

• AAs are always under the “medical direction” of an anesthesiologist

Ordinarily, an anesthesiologist should not furnish additional services to other patients while concurrently directing the administration of anesthesia. Benefits may be provided if the anesthesiologist provides any of the following services to other patients while medically directing the administration of anesthesia without affecting their ability to administer medical direction:

• Addressing an emergency of short duration in the immediate area, such as:

1. Labor epidural placement and management;

2. Responding to medical emergencies or urgencies of short duration (i.e., establishing intravascular access in patient whose quality of care is reduced without it, tracheal intubation, advanced circulatory life support (ACLS) provision, etc.);

• Administering an epidural or caudal anesthetic to ease labor pain;

• Administering an epidural steroid injection or trigger point injection requested by another physician. The epidural or trigger point injection may only be done in compliance with the 1:4 ratio. This does not include consults to diagnose and treat. The intent of allowing this practice is enhancement of efficiency in providing these comonly requested procedures. The intent is not to allow or encourage anesthesiologists to schedule and provide a full service chronic pain management clinic while also concurrently attempting to provide the care to patients receiving surgical anesthesia under his or her direction. The consult for performance of an epidural or trigger point may serve as the second, third, or fourth concurrent case. This means that performing limited pain services is not allowed while medically directing four concurrent anesthetics. The anesthesiologist involved is responsible for being sure his or her ability to respond to urgent or emergent needs in operating rooms, labor and delivery rooms, or any other place in the hospital where responsibility may be, is not unsafely reduced at any time;

• Periodic rather than continuous monitoring of an obstetrical patient;
• Receiving patients entering the operating suite for the next surgery;
• Checking on or discharging patients from the post anesthesia care unit; and/or
• Coordinating scheduling matters.