# CRNA in ASC Billing



## kjonesaapc (May 15, 2009)

I am billing for a CRNA who is providing propofol sedation for endoscopy patients in an ASC and I need coding help for Medicare. 
I  billed first with the 00740 or 00810 and the  QZ and the P (physical status modifier). Medicare denied for "wrong or missing modifier." 
I billed again with the same CPT and QZ, QS and the P modifiers and Medicare denied with the same remark.
I billed again with the same CPT and just QZ and QS modifiers and Medicare denied with the same remark.
I billed again with the same CPT and just QZ and Medicare againg denied saying "wrong or missing modifier." 
I have run out of combinations of modifiers and have still had no success with getting these claims processed by Medicare. The commercial payers were all ok with the first modifiers I sent but I just can't seem to get the Medicare coding requirements correct. I am in CA and have called Palmetto but can not get through to a person there for guidance.
I would be very appreciative of any insight that anyone might have that would enable me to bill these services according to Medicare/Palmetto guidelines. Thank you.


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## jdrueppel (May 20, 2009)

If the service was personally performed by the CRNA then the QZQS (in this order) are the appropriate modifiers.  However, per the CMS Website, California is NOT an opt out state.  If so this means services performed in California by a CRNA cannot be performed without medical direction or supervision and based on this information, the QZ modifier would not be appropriate.  Instead the modifiers for this service would be QXQS.  In addition, there is a 50% fee schedule reduction for the QX modifier. I do not have specific California CRNA licensure limitiation so I strongly urge you to confirm the opt out information with your provider, another CA CRNA anesthesia practice, and/or Palmetto.  I have attached some references below.

Palmetto anesthesia modifier link:
http://www.palmettogba.com/palmetto...esthesiology~2047E0EC4E021BA78525759F004BCA58

CMS CRNA opt out info per CMS Website:

Anesthesia Supervision
CMS established an exemption for Certified Registered Nurse Anesthetists (CRNAs) from the physician supervision requirement by recognizing a Governor's written request to CMS attesting that he or she is aware of the State's right to an exemption of the requirement and it is in the best interests of the State's citizens to exercise this exemption on November 13, 2001.
At this time, fourteen states have chosen to opt-out of the CRNA physician supervision regulation.  Those states are:  Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin and Montana. 

Hope this helps.
Julie, CPC


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