Anesthesia Coding Alert

Before you can code medical direction for anesthesia services during surgery, the anesthesiologist must document his or her presence during all critical or key portions of the procedure. These guidelines - known as the seven rules of medical direction - must each be met before you can code the anesthesiologist's case as medically directed (by appending modifier -QY, Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist; or -QK, Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals).
 
To code medical direction, the anesthesiologist must:
 

perform a preanesthesia examination and evaluation
 

prescribe an anesthesia plan
 

personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence
 

ensure that any procedure in the plan that he or she does not perform is performed by a qualified anesthetist
 

monitor the course of anesthesia administration at intervals
 

remain physically present and available for immediate diagnosis and treatment of emergencies
 

provide the indicated postanesthesia care.