Anesthesia Coding Alert

New Medicare guidelines require that supervisory physicians working in a teaching setting clarify documentation of their services. If your physicians work in a teaching capacity, be sure their documentation supports it before coding with modifiers such as -GC (This service has been performed in part by a resident under the direction of a teaching physician).

Although the new guidelines state that teaching physicians don't need to repeat documentation provided by a resident, their supporting notes need to be more thorough than "Discussed with resident. Agree," or "Agree with above," says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. (These types of documentation are unacceptable because they don't show that the teaching physician was present, evaluated the patient and/or was involved in the patient's care plan.)

Instead, the teaching physician must personally document that he or she performed the service or was physically present when the resident performed key or critical portions of the service, and the extent of his or her participation in the patient's management. The physician must also personally write (or dictate), sign and date the note. Signing and dating beside a stamp, decal or other preprinted version of minimally acceptable documentation wording is no longer valid (some carriers may have accepted this in the past, but the new nationwide policy overrides it).

Remember that the anesthesiologist's involvement in the case determines which performance modifier he or she reports. If the case does not qualify for the teaching physician modifier (-GC), choose from -AA (Anesthesia services performed personally by anesthesiologist), -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist), -QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals); -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures), -QX (CRNA service: with medical direction by a physician), and -QZ (CRNA service: without medical direction by a physician).

Some coders use multiple modifiers to describe cases involving residents and other caregivers, such as -QK/ -GC (which indicates that the service was performed in part by a resident or student registered nurse anesthetist [SRNA] under the direction of a teaching physician). But Groudine says this may not be necessary because Medicare doesn't pay for resident services in the operating room when they are in conjunction with other medically directed cases.

"Medicare says residents aren't able to bill Part B for anesthesia services," he explains. "Therefore, if I'm performing a case with a nurse anesthetist in one room and a resident in the other and both cases are Medicare, I bill -QK and -QX for the case I perform with the CRNA. I bill -QK for the other case but usually don't send the resident's bill because it isn't paid. Residents are only reimbursed if the case qualifies as -AA/-GC, meaning the anesthesiologist worked one-on-one with a resident."

For example, if an anesthesiologist works one-on-one with a resident during a bronchoscopy, code the case as 00520-AA-GC (Anesthesia for closed chest procedures [including bronchoscopy]; not otherwise specified).

Before billing for anesthesia services during surgery, the teaching physician must document his or her presence during all critical or key portions of the procedure. These include the seven parts of medical direction that specify the anesthesiologist must: