Medical Direction vs.
Medical Supervision

As anesthesia practices face ongoing clinical staffing shortages and increased labor costs, they are sometimes forced to consider alternatives to the status quo. One such option is looking at medical supervision, which involves one anesthesiologist overseeing 5 or more concurrent CRNA rooms.

Understanding the Medical Supervision Model

To understand the medical supervision model, we first need to look at how Medicare and other insurance companies pay for anesthesia:

  • Personally Performed by Anesthesiologist (claims modifier AA):
    Payment typically 100% of unit rate
  • Medically Directed case involving Anesthesiologist & 1-4 CRNAs
    (claims modifiers QY/QK & QX)

    Payment typically 50% of unit rate for each billable provider
  • Medically Supervised case involving Anesthesiologist & 5+ CRNAs (claims modifiers AD & QX):
    Payment of 4 total units to Anesthesiologist if present at Induction, 3 total units if not (no 50% reducation). CRNA receives standard 50% of unit rate.
    *Anesthesiology Assistants, Residents & SRNAs do not conform to this model.
  • Non-Medically Directed case involving CRNA (claims modifier QZ):
    Payment typically 85-100% of unit rate.

Clinical Model Selection By Service Line

Now that we understand the general payment system, let’s take a more granular look at how total anesthesia units (base + time) can factor into a group’s decision on clinical model selection by service line, using the guide below:

Medical Decision Model total anesthesia units

* Calculations based on 2023 Medicare National Anesthesia CF
* Calculations based on Anesthesiologist’s presence at Induction

Medical Supervision Use Cases

As you can see, Medical Supervision works well in venues with low acuity and short duration cases, such as GI and Eyes. Since the surgeons for these cases tend to work on specific days and utilize the same perioperative service locations, it’s easier to designate as a “Supervision” sublocation, since the total anesthesia unit value is consistent and predictable. The same cannot be said of standard Operating Room locations, which are a mixed bag.

Benefits of Medical Supervision

The benefits to a Supervision model include fewer FTE Anesthesiologists to staff, no 4-room maximum for CRNAs, and the removal of the onerous TEFRA documentation requirements, other than remaining immediately available.

Not "One Size Fits All"

It’s important to note that practices don’t have to take a “one size fits all” approach to their clinical scheduling. Most groups will find their main ORs to be better suited for medical direction, while certain perioperative locations may merit consideration for Medical Supervision.

Whatever you decide, it’s advisable to detail within your compliance plan and let your biller know, to avoid unnecessary “concurrency send-backs”.

Lastly, you’ll want to check your larger payors’ anesthesia policies, to ensure that their Supervision payment (AD/QX) is consistent with Medicare. It’s also recommended that you review your facility bylaws and malpractice insurance coverage, prior to implementing. 

This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document.  All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.

Hal Nelson, Vice President Anesthesiology Services


VP of Anesthesiology Services

Hal has 30+ years of experience on both the payor and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.

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