When a physician medically directs a CRNA or an anesthesiologist assistant, the claim must carry the correct provider modifiers. The autocoder reads the attestation language in the record. It then evaluates that evidence against the TEFRA medical direction requirements, and the outcome drives the modifiers on the claim.

Your facility configuration controls every behavior on this page. Contact your Hank representative to change it.

## The requirements the autocoder evaluates

CMS defines seven requirements for medical direction. The autocoder evaluates the "most demanding portions" requirement as two separate checks, one for induction and one for emergence. This produces eight results per case.

| Requirement | Configuration key |
|---|---|
| The physician performed the pre-anesthetic examination and evaluation | `mdPerformedPreAnestheticExam` |
| The physician prescribed the anesthesia plan | `mdPrescribedAnesthesiaPlan` |
| The physician was present for induction | `mdPresentForInduction` |
| The physician was present for emergence | `mdPresentForEmergence` |
| The physician ensured qualified providers performed procedures | `mdEnsuredQualifiedProviders` |
| The physician monitored the course of anesthesia at frequent intervals | `mdMonitoredAtFrequentIntervals` |
| The physician remained present and available for immediate diagnosis and treatment | `mdPresentForCriticalPortions` |
| The physician provided indicated post-anesthesia care | `mdProvidedPostAnesthesiaCare` |

Each requirement receives one of three results: MET, UNMET, or EXCLUDED. EXCLUDED means the requirement does not apply to this case. The autocoder records the evidence and the reason for every result, so a reviewer can see why a requirement passed or failed.

## When a requirement is excluded

The autocoder excludes a requirement in these situations:

1. Your configuration sets the requirement key to `false`. The requirement then reports EXCLUDED instead of being evaluated.
2. The anesthesia type has no induction or emergence phase, for example MAC, regional, spinal, or epidural. The induction and emergence checks report EXCLUDED.
3. The case duration is 60 minutes or less. The frequent monitoring check reports EXCLUDED, because CMS treats induction and emergence documentation as sufficient for a short case.
4. The case has no procedure that falls under the supervision policy. The qualified providers check reports EXCLUDED.

The autocoder also recognizes physician-only staffing. If the record documents an attending physician and no CRNA, assistant, or resident, the autocoder treats the presence and monitoring requirements as met.

## Attestation strictness

The `monitoringStrictness` setting controls how the autocoder reads borderline attestation text for the presence and monitoring requirements. Three tiers exist:

- `strict`: accept only explicit phrasing, for example "monitored at frequent intervals" or "present for induction".
- `moderate`: also accept clearly implied oversight, for example "supervised the anesthetic" or "present throughout the case".
- `lenient`: accept any documented physician oversight, presence, or involvement.

The shipped anesthesia configuration uses `moderate`. Discuss any change with your compliance lead first, because the tier changes how often a requirement reports UNMET.

## What happens when criteria are met or not met

Two settings control the billing outcome. `actionWhenCriteriaMet` is optional. Leave it out and normal billing proceeds with your configured provider scenarios. Set it to `bill_md_no_modifiers` to place the physician on the line without direction modifiers.

`actionWhenCriteriaNotMet` accepts these values:

| Value | Result |
|---|---|
| `continue_with_hre` | Bill the configured scenario and add a compliance review alert. This is the shipped default. |
| `drop_to_crna` | Bill the CRNA as non-directed with modifier QZ. |
| `drop_to_crna_no_hre` | Same as `drop_to_crna`, and suppress the unmet review alert. |
| `drop_to_supervision` | Change the physician line to supervision billing with modifier AD. The CRNA line bills with modifier QX. |
| `hardstop_keep_md` | Keep the physician on the line and raise a HARDSTOP alert for coder review. |

Use `actionWhenCriteriaNotMetAA` to set a different outcome for assistant cases. `hreType` and `hreSeverity` set the type and the severity of the unmet alert. The shipped values are COMPLIANCE and severity 8.

Concurrency has its own pair of settings. `maxConcurrentCases` records your limit, which CMS sets at 4. `actionWhenConcurrencyExceeded` chooses between `drop_to_supervision` and `hardstop`.

## The modifiers the autocoder emits

The evaluation result and your provider scenarios decide the modifiers. The autocoder emits AA, QK, QX, QZ, AD, and GC.

- QK goes on the physician line when a physician directs a CRNA or an assistant.
- QX goes on the directed CRNA or assistant line.
- QZ goes on a CRNA line when no physician directs the case.
- AA goes on a physician-only line, and pairs with GC on a teaching case.
- AD goes on the physician line only under the `drop_to_supervision` outcome.

The autocoder does not emit QY. It emits QK for every directed case, and your downstream billing system converts QK to QY when direction is one to one. For each modifier and its documentation requirements, read [Anesthesia Modifiers](/hank-codes/coding-reference/anesthesia-modifiers).

## The review alerts you can expect

| Alert | Alert id | Type and severity |
|---|---|---|
| TEFRA requirements satisfied | `tefra_all_requirements_met` | INFORMATIONAL, severity 2 |
| TEFRA requirements unmet | `tefra_requirements_unmet` | Set by `hreType` and `hreSeverity` |
| TEFRA override applied | `tefra_override_applied` | INFORMATIONAL, severity 3 |
| TEFRA evaluation failed | `tefra_evaluation_failed` | COMPLIANCE, severity 8 |

The unmet alert names the requirements that failed and the recommended action. The override alert fires alongside it whenever an outcome changed the billing shape. The failed alert means an automated check did not complete, so a coder must verify medical direction compliance by hand.

To turn medical direction billing off completely, set `medicalDirection.enabled` to `false`. The autocoder then skips the evaluation and bills physician-performed or non-directed lines only.

## How these alerts reach you

What happens next depends on how your organization consumes HANK CODES. In HANK Claim Maker, a COMPLIANCE alert flags the claim for your compliance team. Organizations that consume the coding API directly decide in their own workflow which alerts pause a claim, who reviews them, and when a claim is released.