Anesthesia

Concurrent, Medical Direction and Supervision

Table of Contents

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Concurrent Medically Directed Procedures

Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient.

For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and the remaining a Medicare patient, this represents three concurrent cases.

A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in rendering additional services to other patients.

However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.

If the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. No fee schedule payment is made.

The examples listed above are not intended to be an exclusive list of allowed situations. It is expected that the medically-directing anesthesiologist is aware of the nature and type of services they medically direct, and they are personally responsible for determining whether his supervisory capacity would be diminished if they became involved in the performance of a procedure. It is the responsibility of this medically-directing anesthesiologist to provide services consistent with these regulations.

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Medical Direction and Temporary Relief

Medical direction of an anesthesiologist must have uninterrupted immediate availability of an anesthesiologist at all times.

When a medically directing anesthesiologist provides temporary relief to another anesthesia provider, the need for uninterrupted immediate availability may be met by any of the following strategies:

  • A second anesthesiologist, not medically directing more than three concurrent procedures, may assume temporary medical direction responsibility for the relieving anesthesiologist. The transfer of responsibility from one physician to another should be documented in the medical record.
  • Policy and procedure may require that the relieved provider remain in the immediate area and be available to immediately return to his/her case in the event the relieving anesthesiologist is required elsewhere. Adequate mechanisms for communication among staff must be in place.
  • Policy and procedure requires that a specified anesthesiologist (e.g., O.R. Director) remain available at all times to provide substitute medical direction services for anesthesiologist(s) providing relief to anesthesia providers. This individual must not personally have ongoing medical direction responsibilities that would preclude temporarily assuming responsibility for additional case(s).

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Medical Directed Rate

Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities:

  • Performs a pre-anesthesia examination and evaluation
  • Prescribes the anesthesia plan
  • Personally participates in the most demanding procedures of the anesthesia plan, including induction and emergence
  • Ensures that any procedures in the anesthesia plan that they do not perform are performed by a qualified anesthetist
  • Monitors the course of anesthesia administration at frequent intervals
  • Remains physically present and available for immediate diagnosis and treatment of emergencies
  • Provides indicated post-anesthesia care

For medical direction services, the physician must document in the medical record that they performed the pre-anesthetic exam and evaluation. Physicians must also document that they provided indicated post-anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedures, including induction and emergence, if applicable.

The physician can medically direct two, three, or four concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs, interns, residents or combinations of individuals.

The medical direction rules apply to cases involving student nurse anesthetists if the physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern or resident.

Medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents.

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Medically Supervised

When an anesthesiologist is involved in rendering more than four procedures concurrently or is performing other services, while directing the concurrent procedures, the anesthesia services are considered medically supervised.

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Revised 10/25/2024