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Free checklist

Medical direction documentation checklist

The seven requirements an anesthesiologist must meet and document for each medically directed case. 13 checks, ready to print.

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What's on it

If any of these can't be shown in the record, the case may need to be billed as medical supervision instead.

The seven requirements, for every directed case

  • Performed the pre-anesthetic examination and evaluation
  • Prescribed the anesthesia plan
  • Personally took part in the most demanding parts, including induction and emergence where they apply
  • Made sure any procedures they didn't perform were done by a qualified anesthetist
  • Monitored the course of anesthesia at frequent intervals
  • Stayed physically present and available for emergencies
  • Provided the post-anesthesia care that was needed

Concurrency

  • No more than four concurrent cases at any time
  • Concurrency tracked with times across the day
  • Cases above the limit billed as supervision, not direction

Claims

  • Anesthesiologist billed QK (two to four cases) or QY (one case)
  • CRNA billed QX for the same case
  • Times on both claims match the record

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