Anesthesia Coding Alert

Your teaching anesthesiologist will get a 50 percent pay boost when he supervises up to two residents and is present during key portions of the case, thanks to changes to the 2010 Medicare Physician Fee Schedule.

Here's what you need to know about the change that goes into effect Jan. 1, 2010, according to CMS's Final Rule on the Physician Fee Schedule released Oct. 30.

The new payment guideline applies to a teaching anesthesiologist's involvement in each of two concurrent resident cases or in one resident case that is concurrent to another case paid under medical direction rules (such as one involving a nurse anesthetist or anesthesiology assistant).

"An anesthesiologist covering a resident should be covering no more than two rooms because residents are there to learn," explains Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. "Medicare follows the two-room rule and will allow anesthesiologists to bill with modifier AA when covering up to two residents." Coding with modifier AA (Anesthesia services performed personally by anesthesiologist) allows 100 percent reimbursement for the service.

Compare the new rates to the old method from CPT, as explained by Kenneth B. Simon, MD, MBA, CMS senior medical officer, in "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the CPT and RBRVS 2010 Annual Symposium in Chicago.

2009 pay scale: Currently, the anesthesiologist gets paid 100 percent for cases he or she personally performs. He gets 50 percent pay when involved in two cases of teaching supervision.

2010 change: Your anesthesiologist will receive full reimbursement for cases he personally performs, when he provides teaching supervision to one resident, or when he provides teaching supervision to two residents (or a resident and another provider covered by medical direction rules) during concurrent cases and is present for key portions of the procedures.

Hand-off hint: Does your coding get confusing when one physician starts a case and another takes over during the procedure? CMS guidelines point you in the right direction by stating that you should report the teaching anesthesiologist who starts the case as the "AA" physician, even if his or her partners perform other aspects of supervising the residents.

You'll also want to include modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) with Medicare cases to indicate your physician's teaching capacity, says Julee Shiley, CPC, CCS-P, ACS-AN, a North Carolina coder. "The CMS rule clearly states that you use both modifiers," Groudine adds. "Without GC it would be hard to understand how the physician could do two cases as 'personally performed' concurrently."

According to the rule, "Documentation must indicate the teaching physician's presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist."

Keep these tips in mind when ensuring you have foolproof documentation during those key portions:

• Medicare requires the anesthesiologist's presence during induction and emergence.

• The anesthesiologist must document interval monitoring of the case.

• The anesthesiologist must be immediately available to provide service whenever needed (including availability immediately before and after the case).

• Documentation must indicate that the anesthesiologist met the teaching criteria. For example, look for comments such as, "Supervision of resident, present for all critical events and/or procedures. Immediately available throughout anesthesia service."

Some initial interpretations of the new rule led coders to believe that you would also report CRNA services differently in teaching situations, but that's not the case. "These rules do not affect anything else so billing and reimbursement between anesthesiologists, CRNAs, and the SRNAs they work with remain unchanged," Groudine says. "Nothing in the new regulations appears to change the ability of an anesthesiologist to medically direct up to four CRNAs whether they work with SRNAs or not."

Translation: You can bill up to four operating room cases for a medically-directing anesthesiologist and CRNAs, provided the physician meets all seven medical direction criteria. You'll report the appropriate procedure code along with:

• Modifier QX (CRNA service: with medical direction by a physician) for the CRNA

• Modifier QK (Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals) for the anesthesiologist.