# Coding Help - So I'm not up to speed yet



## jthomas (Mar 24, 2014)

So I'm not up to speed yet on anesthesia coding, but I have an anesthesiologist and a CRNA performing the service.  Can I bill for both?


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## dwaldman (Mar 25, 2014)

Below are the requirements for anesthesiologist providing medical direction of a CRNA. They allow up to 4 concurrent anesthesia procedures. QK modifier would be reported if the medical direction criteria was met for the anesthesiologist if he/she was providing medical direction of 2, 3, or 4 cases. The CRNA would separately report the case with the QX modifier. If the anesthesiologist is providing medical direction of one CRNA then the QY modifier would be used and the CRNA would report QX. Additional modifier QS is reported to indicate the service was monitored anesthesia care. Refer to PQRS Measure #30 for reporting of timing of the IV antibiotic 1 prior to surgical incision. And PQRS Measure #193 for perioperative temperature management.

Below is from the CMS internet only manual 100-04 Chapter 12


QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;  
QS - Monitored anesthesia care service;  
QX - CRNA service; with medical direction by a physician;  
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;  
QZ - CRNA service:  without medical direction by a physician; and 


C. Payment at the Medically Directed Rate  The Part B Contractor determines payment for the physician?s medical direction service furnished on or after January 1, 1998, on the basis of 50 percent of the allowance for the service performed by the physician alone.  Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities.  
? Performs a pre-anesthetic examination and evaluation;  
? Prescribes the anesthesia plan;  
? Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;  
? Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;  
? Monitors the course of anesthesia administration at frequent intervals;  
? Remains physically present and available for immediate diagnosis and treatment of emergencies; and  
? Provides indicated-post-anesthesia care.  
Prior to January 1, 1999, the physician was required to participate in the most demanding procedures of the anesthesia plan, including induction and emergence.  
For medical direction services furnished on or after January 1, 1999, the physician must participate only in the most demanding procedures of the anesthesia plan, including, if applicable, induction and emergence.  Also for medical direction services furnished on or after January 1, 1999, the physician must document in the medical record that he or she performed the pre-anesthetic examination and evaluation.  Physicians must also document that they provided indicated post-anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedures, including induction and emergence, where indicated.  
For services furnished on or after January 1, 1994, the physician can medically direct two, three, or four concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs, interns, residents or combinations of these individuals.  The medical direction rules apply to cases involving student nurse anesthetists if the physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern or resident.  
For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents.  
If anesthesiologists are in a group practice, one physician member may provide the pre- anesthesia examination and evaluation while another fulfills the other criteria.  Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service.  However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.  
A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in furnishing additional services to other patients.  However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous, monitoring of an obstetrical patient does not substantially diminish the 
scope of control exercised by the physician in directing the administration of anesthesia to surgical patients.  It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met.  Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.  
However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician?s services to the surgical patients are supervisory in nature.  Carriers may not make payment under the fee schedule.  
See ?50.J for a definition of concurrent anesthesia procedures.


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## hgolfos (Mar 25, 2014)

This depends somewhat on payer.  Some payers, such as Medicare and Medicaid require a claim for each provider.  Some payers, such as Blue Cross Blue Shield in some states, only want one provider.  Check with your big payers to find out how they want them billed.


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