Change in the CRNA Supervision Rule: A New Ballgame for Anesthesia?

Summary

The recent waiver of the rule requiring CRNAs to be supervised by a physician may lead to some confusion. Does this mean a change in the medical direction rules? Does this lead to any change in billing? This article addresses what this waiver does and what it does not do.

Among the many emergency rules and waivers the Trump administration has issued over the last few days is a short paragraph concerning physician supervision of CRNAs. Here is the text that was found on the CMS.gov “Newsroom” website:

CMS is waiving the requirements that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician. This will allow CRNAs to function to the fullest extent allowed by the state, and free up physicians from the supervisory requirement and expand the capacity of both CRNAs and physicians.

Some of our clients have wondered if this waiver will change the billing or medical direction rules as it concerns CRNAs. Does this waiver mean that all cases involving CRNAs must now be billed with the QZ modifier, indicating services of a non-medically directed CRNA? The answer to that question is “no.”

While there is relatively little clarification within the above CMS excerpt, the wording appears to be addressing a temporary suspension of the federal “conditions of participation” (CoP) mandate regarding CRNA supervision, as found at 42 CFR § 482.52(a)(4). That rule states in pertinent part:

A certified registered nurse anesthetist (CRNA), as defined in § 410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed.

As an aside, “paragraph (c),” referenced immediately above, allows states to “opt out” of this physician supervision requirement. Several states, prior to this national waiver, have taken advantage of this paragraph (c) allowance and have been operating under an opt-out status for some time.

Different Types of Supervision

In the anesthesia world, some individuals tend to use the term “supervision” in a broad, generic or imprecise way. Some will use it to describe medical direction. Others will use it to describe the collaboration model (non-medical direction). Then there is of course the anesthesia-specific term of art “medical supervision.” Don’t forget about the terms “direct supervision” and “indirect supervision” as it concerns RNs and NPs in a clinic. With all these various layers and meanings and applications of the term “supervision,” it is no wonder that many in the medical industry will get confused as to what’s really being described.

The term “supervision,” as used within the CoP rule, is a completely different animal from all the scenarios described immediately above (though collaboration comes close). It has nothing to do with medical direction, non-medical direction or medical supervision. It has nothing to do with how you bill or the modifier you use. Since many people may be unclear on this particular supervision rule, which I will refer to as “CoP supervision,” it may be helpful at this juncture to describe what it means.

CoP Supervision

To clarify, CoP supervision simply means that a physician—whether that be the surgeon in the operating room (OR) or an anesthesiologist—must remain immediately available to the CRNA should an issue with the patient arise. Again, this is separate and apart from the medical direction rules. For example, in the CoP rule, supervision is achieved based on a specifically defined proximity being observed by the physician relative to the CRNA. In its “interpretive guidelines” (IGs) concerning this part of the CoP rule, CMS states that the surgeon (“operating practitioner”) is in the same OR as the CRNA or an anesthesiologist is in the “same area” as the CRNA. The IGs went on to define “same area” as “the same OR suite” or “the same L&D unit.” 

This is different from the medical direction rules where there is no specifically prescribed proximity a medically directing doctor must maintain vis-à-vis the CRNA. For instance, many anesthesiologists will be medically directing on one floor, i.e., the surgical suite, and go a different floor to insert a labor epidural in the L&D unit. Technically, under the CoP supervision rule, that anesthesiologist, while still medically directing, is no longer providing CoP supervision to the CRNA while in the L&D unit; but all is well, because the surgeon is still in the same room with the CRNA. “Physician supervision,” i.e., CoP supervision, of the CRNA is maintained.

The New Waiver

It is our belief that it is this CoP supervision rule that is being waived with the government’s recent press release (as previously provided in the above excerpt). If this interpretation is correct, the new waiver is simply making every state in the country effectively an "opt-out" state as it concerns the CoP supervision of a CRNA during this national emergency. This means simply that there is no longer a “proximity” threshold that must be met by a physician as it concerns the CRNA’s case work—whether that case involves an anesthetic, critical care or other procedure. (We should note here that the waiver is removing the federal rule that CRNAs must be under supervision. The waiver language about “the fullest extent allowed by the state,” may mean that this waiver may not be effective if there is a state rule or regulation in place that requires physician supervision of the CRNA. We recommend you review your state scope of practice rules to determine if such language exists.)

Groups That Medically Direct

It must be stressed, however, that the waiver of the CoP supervision rule does not abrogate the medical direction rules. Recall that even in the opt-out states, prior to the current national waiver, there were groups that followed a medical direction model. In such a model—even in opt-out states—the medically directing doctor was still expected to follow the medical direction rules. As such, the CRNA’s claim would still be billed out with the QX modifier, not QZ. In the same way, now that CRNAs in every state can practice without the CoP supervision of a physician (assuming there is no state-specific prohibition), the medical direction rules will still apply to the medically directing doctor--including remaining available (which, unlike the CoP supervision rule, is undefined as to the issue of proximity). 

Accordingly, this change will have no impact on using QZ vs QK for CRNA anesthesia services. Those modifiers will continue to be determined by the presence or absence of medical direction. So, to summarize, from a billing perspective, the new temporary waiver of the CoP supervision rule will not bring any change to medically directing groups, as the medical direction rules remain in place.

We will continue to update you on any changes that we believe will be relevant to your practice during this extraordinary time for our country and our healthcare industry. Please email us at [email protected]. Our thanks go out to all of you on the front lines of this national emergency.