Anesthesia Coding Alert

Ask, “Is it supervision, medical direction, or non-medically directed?”

A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who is an anesthesia specialist able to administer anesthesia independently or under physician medical direction or supervision. Although not recommended by the American Society of Anesthesiologists (ASA), any physician providing medical direction or supervision is not required to be an anesthesiologist.

Reporting claims for a CRNA with carriers other than Medicare can be confusing, as you need to consider employment status, state scope of practice laws, carrier recognition, and the practical considerations of how to effectively file claims and calculate separate charges, when applicable, before determining the correct method.

Here are five things you should know to file clean CRNA claims.

1. Know Who Employs the CRNA

This is one of the most important aspects to consider. CRNAs may be self-employed and bill for their own services. However, a recent report from the National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA) indicated that just 18 percent are independent contractors. Most CRNAs (41 percent) are hospital employees, while 25 percent work for anesthesia groups.

CRNAs and those who employ them must accept assignment on their claims; however, filing rules for the various insurance carriers differ.

2. Know State Scope of Practice Laws

State scope of practice laws vary in their determination of whether direction or supervision of a CRNA by a physician is required. So, it is important to research local policy for your state and geographic region to determine how to bill a CRNA.

If your state requires surgeons to supervise nurse anesthetists, you bill CRNA services as non-medically directed, as a surgeon may not wear two hats and collect payment for being both the surgeon and the medically directing physician. However, as of May 2024, 25 states have opted out, either partially or fully, from the Medicare rule requiring a CRNA to be medically directed or supervised by a physician.

Stay on top of the regulations: Consult the AANA’s State Reimbursement Specialist (SRS) Program to understand how insurance payments are allocated for CRNAs in each state and ensure that CRNAs are paid for their services. The ASA also monitors state by state information.

You should also keep a spreadsheet with your findings, update the information at least once a year, and maintain either a print or electronic copy of each state’s policy in the event the policy changes.

3. Know Payer Payment Policies

If an anesthesia group employs the CRNA, under Medicare, payment for a medically directed case by an anesthesiologist and a CRNA and payment for a non-medically directed case performed solely by a CRNA are revenue neutral, meaning payment is equal.

When billing, however, a MD/CRNA care team does not have to report Medicare modifiers to all insurance companies, and doing so may cause denials, as not all carriers recognize the same HCPCS Level II modifiers. Once again, the best advice is to check with applicable state insurance plans and payers to determine how anesthesia services are billed. Although not all plans do so, many anesthesia policies are available online. Just remember to periodically check for changes or updates and, if possible, subscribe to payer websites for notifications.

Some private insurers do not publish policy and may expect CRNA services to be billed under the anesthesiologist on one line of the claim form. Reporting separately may result in a claim denial or improper payment.

When a CRNA is employed by a hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others, depending on several factors. First, not all carriers recognize split claims or HCPCS Level II modifiers and expect to receive only one bill for anesthesia services. Unless the hospital billing department and the anesthesia group have a previous billing arrangement regarding anesthesia services, you should expect the “quickest claim filed” rule to come into play. In this scenario, the first claim processed receives payment, while the second claim is typically rejected, ignored, or denied as a duplicate service.

According to Horizon Blue Cross and Blue Shield’s (HBCBS’s) Reimbursement and Billing Guidelines for Anesthesia Claims, “When billing Horizon BCBSNJ for services rendered, submit your full charges for the applicable CPT-4 codes on both the CRNA claim line and the anesthesiologist claim line. Do not split the total charge between the CRNA and the anesthesiologist. Our systems will adjudicate the claim lines to calculate 50 percent of our allowance for both the CRNA and the supervising anesthesiologist for the service provided.”

In addition, Medicare Administrative Contractor (MAC) Novitas and other MACs offer a “pass through” billing option for Critical Access Hospitals (CAH), which can either be accepted or declined. Novitas allows different ways to bill this, depending on whether the CRNA accepts or declines the pass-through exemption. If CAH receives pass-through payments, the CRNA is prohibited from billing Medicare Part B for anesthesia services furnished to patients of that hospital.

A Note on Modifier QZ: The HBCBS policy above states that services with Modifier QZ (CRNA service: without medical direction by a physician) appended “are not eligible and should be denied.”

4. Know The 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 for billing purposes, and use of medical direction and supervision modifiers affects payment for anesthesia claims.

Medical direction (indicating the physician has met all applicable Center for Medicare and Medicaid (CMS) requirements) effectively pays 100 percent of the claim.