Anesthesia Coding Alert

Look before you leap into using these tricky modifiers

When an anesthesia case involving incomplete medical direction arrives on your desk, some coders might consider creating a claim in the CRNA's name and appended modifier QZ (CRNA service: without medical direction by a physician).

Before taking that route, keep three tips in mind.

1. Start With Your Local Carrier

CMS does not have a national-level policy for incomplete medical direction. "Instead, CMS has directed the local carriers to address this issue case by case," says Cindy Hinton, CPC, CHCC, with Advanced Coding Solutions in Whitehouse, Tenn. "The final determination can vary, depending on the circumstances."

But, in general, the CRNA could submit the claim by using modifier QZ, or the physician might report the procedure using modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures).

Caution: If the anesthesiologist reports modifier AD, the CRNA should report modifier QX (CRNA service: with medical direction by a physician) instead of QZ. If you submit modifier QZ, the carrier will erroneously pay 100 percent of the CRNA's services in addition to the physician reimbursement -- leading to an inadvertent over payment for services.

Smart move: Be clear about who employs the CRNA to ensure that the proper entity files the claim. If the group employs the CRNA, it may file the CRNA services with its services (just keep in mind that the group doesn't necessarily need to report these modifiers). If the group doesn't employ the CRNA, the payer usually pays the first claim filed and rejects the second claim.

Play it safe: Check with your payers to make sure that they recognize all of the HCPCS modifiers you plan to include in your claim. Your reporting method may depend on the exact circumstances that rendered medical direction incomplete.

2. Save Headaches by Explaining Circumstances

Submitting a claim that clearly indicates the portion of the case that met medical direction ��" as well as the portion that didn't -- allows the payer to make a decision based on the circumstances for your specific claim. In some cases, carriers will still allow reimbursement for the entire claim based on medical direction. Regardless of the appropriate reporting method for your case, always remember that you must consider the physician's time involved when reporting concurrent cases.

"By submitting a claim for the CRNA with modifier QZ, you might have eliminated the physician from the claims process," Hinton says. "But you still have to account for his or her time involvement when calculating concurrency and determining the correct modifiers for any concurrent cases."

3. Keep Your Medical Direction Compliant

You need to be familiar with the seven steps of medical direction and the exceptions that Medicare allows. The anesthesiologist can perform certain services (such as receive patients entering the operating suite for the next surgery) without interrupting medical direction.

Local watch: The medical direction "exceptions" vary by state, which can make coding tricky. Several state Medicare Administrative Contractors (MACs) publish Frequently Asked Questions which explain and might allow additional services, such as placing an arterial line while medically directing. Know those services your MAC allows ��" and make absolutely sure that your physician hasn't met the requirements before you start to alter your claims. Watch for more on the ins and outs of medical direction in the next issue of Anesthesia Coding Alert.