ACE ALERT: Medical Direction Elements

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ACE Alert, April 28 2021, Volume 18

Anesthesia Groups Reviewing Medical Direction Elements for Compliance is Essential

In December, the OIG announced a settlement involving the University Medical Associates of The Medical University of South Carolina (UMSC) costing the group $81,000.00.  The OIG alleged that UMSC submitted claims for anesthesia services performed by a certified registered nurse anesthetist claiming medical “direction” by anesthesiologists when the services rendered should have been billed under medical “supervision,” a lower-paying service.  

Two things should be noted.  First, this was a self-disclosed case.  UMSC brought this issue to the government explaining the shortfall.

Second, this is in the MAC Jurisdiction M and the CMS contractor for this region is Palmetto GBA, LLC.  Based on a review of their website, they do not give written instruction on what modifiers should be billed for “intended but failed” medical direction.  

This is the first settlement that we have seen that the government is truly enforcing the difference between medical direction and medical supervision.  Focused reviews should be done on the specific elements documented within the anesthesia pre-evaluation and anesthesia record to evaluate compliance.  

The medical direction rules and exceptions can be reviewed here:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf start reviewing at Section 50C (page 93).  

If ACE can help with a review of documentation and claims for medically directed services, do not hesitate to give us a call.  


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