Supervision of a CRNA: A Concept Without a Reliable Definition


Physician supervision of Certified Registered Nurse Anesthetists has been a hot topic lately. But just what IS physician supervision exactly? Good luck in answering that one without a manual answering the following questions, and good luck finding one of those:

  • Does a Certified Registered Nurse Anesthetist (CRNA) have to be supervised by an anesthesiologist?
  • Does a CRNA have to be supervised by any physician? If so, what kind?
  • What is that option available to states (the opt-out) to pass laws so that CRNAs do not have to be supervised? Isn’t that just a Medicare/Medicaid billing issue?
  • Don’t anesthesiologists say that CRNAs should be supervised by an anesthesiologist?
  • Isn’t there a law that requires CRNAs be supervised?
  • I am a surgeon and if a CRNA is giving anesthesia to my patient without an anesthesiologist supervising, am I liable if there is a problem related to the anesthesia procedures? If I have an anesthesiologist I am not liable right?
  • What does “supervision” mean? What about “medical direction?” What about “collaboration” or “cooperation” or “consultation”?
  • I hear terms like “physically available”, “immediately available” and plain old “available”….what the heck is the difference?
  • How did this become so confusing, and who decides the definitions of all these words, and creates the rules?

Similar to our first article about the Standard of Care in anesthesia, the answers to many of these questions depends entirely on who is asking and for what reason. You likely will receive different answers based on the profession, personal agenda, or personal experience of the individual you ask. To even begin to answer any of them you have to split yourself in two. Self #1 (Insurance Self) asks each question followed by the phrase “when billing an insurance company for anesthesia services”. Self #2 (Law Self) follows each question with “and don’t talk to me about billing insurance companies, just give me a straight legal answer.”

Unfortunately, Insurance Self and Law Self also then have to ask additional questions. Insurance Self needs to know what insurance company is being billed and in what state, and what terms listed above are used, if any, and how each individual insurance company defines them. Law Self needs to know what state you are practicing in, what the state law says specifically and which of the various terms mentioned above are used in state law, if any, and whether the state law goes on to define the term.

Both may find that there are actually no definitive answers, especially when it comes to definitions of terms…..which affects, and confuses even, anesthesia providers.

And all of this is rather important, since it directly affects if, and how much, an anesthesia provider will get paid for their services from an insurance company, whether or not a state licensing board will discipline them, the validity and outcome of a medical malpractice lawsuit, the cost of health care for us all, the cost to a hospital in provision of surgical and anesthesia services (passed on to the patient), and finally because it is tiresome and mentally exhausting to have to try and answer these questions over and over.  VERY tiresome and cerebral intensive if you are actually trying to answer correctly.

If you have any hope of this article making sense as you read it, you are going to have to pretend that you have never heard the words ‘supervision’ or ‘direction’ and abandon whatever definitions of these words you have stored in your brain. In exchange you will only be given reasons why there is no one single correct answer to most of the questions, since that is the most appropriate way of answering them without state specific and insurance carrier specific information.


From the Meriam Webster Online Dictionary:

SUPERVISION (which leads to defining DIRECTION):

Date: 1640 : the action, process, or occupation of supervising; especially : a critical watching and directing (as of activities or a course of action). Supervising: to Superintend, whose definition is: to have or exercise the charge and oversight of, or DIRECT, whose definition is: a : to regulate the activities or course of, b : to carry out the organizing, energizing, and supervising of.

Whoever can now explain the meaningful difference between supervision and direction functionality in the English language, please leave a comment. No need if you want to discuss Latin and Middle English origins and their time periods. I read all that and was very bored. Also, I was rather inconsiderate in first asking you to forget you ever heard these terms and then giving you their common English definitions, but the good news is these definitions are meaningless for the rest of the discussion.

Supervision and medical direction are common, everyday terms used by the insurance industry in determining how much they will pay for anesthesia services, and to whom. Even then rules vary from state to state and insurance company to insurance company, but the definitions they invented and use remain similar in their affront to the English language. ONLY in the insurance industry will the terms mean the same thing somewhat consistently. BUT, they still do not have common sense definitions and you have to still must suspend everything you have learned about the words supervision and direction if you hope to understand any of this.


It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.  Medical Direction ([when] the physician has met all the requirements, if applicable) effectively pays 100% of the claim.  Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.  Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction.  No time is allowed for any of the concurrent cases.    You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.

OK…now you should be confused


Supervision or medical direction, collaboration, consultation, etc. are also terms used in various state nurse and medical practice act regulations….and there is no rhyme or reason as to when they are used or what they mean.

Independent CRNA practice has existed for over 100 years. Only 12 states require by law that a physician ‘supervise’ a CRNA’s practice of anesthesia as a matter of law.

33 states do not have any physician “supervision” requirement for CRNAs at all in their nursing practice or medical practice laws or regulations. The laws of every state permit CRNAs to work directly with a physician or other authorized healthcare professional (for example, dentists and podiatrists) without being supervised by an anesthesiologist. In states which do require physician supervision, the supervising physician is not required to have any training in the practice of anesthesia or additional qualifications with the exception of New Jersey and Washington D.C. (exception applies in D.C. only when a general anesthesia is given). What constitutes ‘supervision’ or ‘direction’ is generally poorly defined or not defined at all. Usually the term hangs in the air without any reference as to what it should mean.


Well, most of the time anyway. WI recently passed an Anesthesia Assistant law which requires they be licensed, which for the past 20 some odd years they did not have to be. The legislature however placed language into the law which says that AAs will be supervised by an anesthesiologist at the ratio determined by Medicare (currently no more than 1:4). This bill was heavily lobbied by the WI Association of Anesthesiologists. So if  you happen to hear one of their members saying “supervision” is a practice issue dictated by quality of care and patient safety, feel free to point out that they are being less than earnest and their own actions have shown, without room for argument, that it is all about $$$$$. Supervise at 1:5 or more = no payment for anesthesia services, stick to the Medicare ratio = get paid.

Insurance reimbursement practices, terms and policies have no business being considered when creating state  medical or nurse practice acts. These acts are supposed to be about the standard of care under which the public health, safety and welfare is  upheld and protected. Science, not the amount of money an insurance company wants to spend, ought dictate medical and nursing practice…no? I know, I know, I live in a fantasy land, but professional organizations and legislatures should at least make the most basic attempts to hide their true agendas if they expect not to be challenged as self aggrandized hypocrites.


 Supervision does NOT create surgeon liability for anesthesia mishaps when a surgeon supervises a CRNA. No greater liability exists for surgeons when they work with CRNAs alone vs anesthesiologists alone. Supervision is not the same as CONTROL over the CRNA and the anesthetic, which is REQUIRED under negligence law for liability to be assigned. For a detailed discussion of this and the law behind it visit our “Supervision Of CRNAs Does Not Create Liability For Surgeons” article.


The American Society of Anesthesiologists has been fighting the ever-present independent practice of CRNAs for decades. In a blast from the past, here is a Parade Magazine article from July 17, 1988 headlining “Doctors and nurses are fighting it out over who should administer anesthesia”.

Anesthesia Battle Royale: Parade Magazine 1988

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2 Responses to Supervision of a CRNA: A Concept Without a Reliable Definition

  1. […] and in their absence such a duty then falls to a surgeon. Supervision as we have discussed is a concept in search of a common definition, often amounting to happening to be present in the room performing an […]

  2. […] This post was mentioned on Twitter by Bart Edwards, Lawmed. Lawmed said: Supervision of a CRNA: A Concept Without a Reliable Definition […]