Medical direction: the seven requirements behind QK, QY and QX

By the Titrate Revenue team · Clinical review by Nelson L., CRNA · Updated October 2026

The seven requirements

For each medically directed case, the anesthesiologist must:

1. Perform the pre-anesthetic examination and evaluation
2. Prescribe the anesthesia plan
3. Personally participate in the most demanding parts of the anesthesia plan, including induction and emergence where applicable
4. Ensure that any procedures in the plan they do not perform are performed by a qualified individual
5. Monitor the course of anesthesia at frequent intervals
6. Remain physically present and available for immediate diagnosis and treatment of emergencies
7. Provide indicated post-anesthesia care

Why it matters for CRNAs

If these requirements are met, the anesthesiologist bills with QK or QY and the CRNA with QX, and Medicare generally splits the fee. If they are not met, the case is not medically directed, and the CRNA's service is billed with QZ.

Documentation is everything

Auditors look for evidence of each requirement in the record. Groups should agree who documents what, case by case, before claims go out.

This article is general information, not billing, legal or tax advice. Payer rules change; always check current guidance.

Sources

• CMS: Medicare Claims Processing Manual, Chapter 12 (Anesthesia)