Who’s at the Head of Your Bed? Anesthesia Delivery in the United States


Michelle Gaines, RN, MNA, CRNA, Nurse Anesthetist, Registered Nurse Expert

You are greeted in the pre-operative area before your surgery by an anesthesia provider.  Is this the same person who will be delivering your anesthesia care during your procedure?  Maybe, but maybe not. There are several care models in the United States: anesthesiologist MD or DO, certified registered nurse anesthetist (CRNA), and anesthesia assistant (AA).  Many anesthetics are delivered in a team model with one anesthesiologist guiding care for up to four anesthetics occurring at the same time, with CRNA’s and AA’s at the head of the bed for a majority of the case.  Who can do what in the anesthesia world is determined by state and national licensing boards, national and state certifications, hospital credentialling, and by-laws.

The terms medically supervised and medically directed are billing terms in the anesthesia world.  Medicare pays for medical direction of CRNA’s and AA’s at a rate of 50% of the reimbursement allowed for the case.  To meet the medical direction requirement of two to four concurrent cases, and receive the other 50% of the reimbursement for each concurrent case, the anesthesiologist must meet the following tax equity and fiscal responsibility act (TEFRA) rules:

  1. Perform the preanesthetic exam and evaluation.
  2. Prescribe the anesthesia plan.
  3. Personally participate in the most demanding procedures in plan.
  4. Ensure procedures that they do not personally perform are performed by a qualified individual.
  5. Monitor the course of the anesthesia frequently.
  6. Remains physically present and available for immediate diagnosis and treatment of emergencies.
  7. Provides indicated post anesthesia care.

“Medically supervised” applies to circumstances where more than four concurrent cases utilizing non-physician providers are occurring.  When this happens, billing can only occur for three base units.  Base units are part of the anesthesia billing calculation determined by the centers for Medicare & Medicaid services annually.

CRNA’s represent more than 80% of the providers in rural counties.  The Cochrane review in 2014 found no difference in care between nurse anesthetists and physician anesthesiologists.  As of 2022, the American Association of Nurse Anesthesia (AANA) has renamed the profession and is now the American Association of Nurse Anesthesiology.  Some states practice acts forbid nurses to present themselves to patients in terminology other than recognized nursing titles. 

It can be very tricky figuring out who is at the head of the bed and when.

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