Revenue Cycle Insider

Question: I’m hoping you can help me with understanding medical direction versus medical supervision.  All cases are being done simultaneously:

• Physician A is medically directing 2 CRNAs (all steps of medical direction are met)
• Physician A is “supervising” 1 CRNA (not all of the steps of medical direction are being met)

Can physician A bill medical direction for the two cases and supervision for the one case?  I know the logical way to do it would be for the certified registered nurse anesthetist (CRNA) to bill modifier QZ [Certified registered nurse anesthetist (CRNA) without medical direction by a physician], but my physicians don’t want to bill that way. Can you give me justification for why we can or cannot bill medical direction and supervision at the same time, or at least point me in the right direction?

Pennsylvania Subscriber

Answer: According to the Centers for Medicare & Medicaid Services (CMS), medical direction and medical supervision are identified by specific modifiers. Medical supervision, as defined by Novitas, the CMS contractor for Pennsylvania, indicates there are more than four procedures and is reported with an AD modifier (Medical supervision by a physician: more than four concurrent anesthesia procedures).

Medical direction of one CRNA/AA by an anesthesiologist is reported with a QY modifier [Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist], whereas medical direction of up to four (excluding teaching services) is reported with a QK modifier (Medical direction of two, three, or four concurrent anesthesia procedures). The CRNA services are reported with a QX modifier [Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist], indicating that a qualified nonphysician anesthetist was medically directed by a physician. In both of these cases, the steps of medical direction must be met.  In the circumstances you described, the anesthesiologist is medically directing three CRNAs (not more than four), but did not meet the documentation requirements for one of the cases. 

Novitas publishes Frequently Asked Questions (FAQs) that address this scenario. According to Novitas, “If the medically directing anesthesiologist does not meet the requirements for medical direction of anesthesia services, the CRNA reports modifier QZ; the anesthesiologist does not bill the service at all.” 

It is particularly important to check with your local Medicare carrier, as not all follow the same guidelines in their FAQs. Other states may be required to report the case that was not documented as medical direction as medical supervision. 

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA,
CPC, CPC-I, Perfect Office Solutions, Contributing Writer