Anesthesia Coding Alert

Establish guidelines to help your medical direction claims.

"Physically present and available" can be one of the trickiest factors to determine when confirming medical direction. Keep these guides in mind when deciding whether your anesthesiologist's claim still merits medical direction modifiers QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) or QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals).

Consider Individual Circumstances

Vague medical direction rules -- such as "remains physically present and available for immediate diagnosis and treatment of emergencies" " allow for individual interpretation. "This is similar to E/M 'incident to' criteria for service in the office," says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J. "The supervising physician for 'incident to' billing must be physically present in the office suite -- but there's a lot of interpretation of 'suite.'"

Accurately defining "immediately available" is more than looking at the hospital's blueprints to see how far your physician walks down the hall. Interpretation also takes each situation into account. For example, the anesthesiologist needs to be more readily available to help during an emergency when he's medically directing an aneurysm repair versus a hernia repair.

Consider these three factors when trying to determine what qualifies as "physically present and available" in your hospital:

OR size: If your group works at a small hospital with only a few operating room suites, the anesthesiologist probably still is immediately available to help with emergencies if he remains in the OR. But if your group works at a massive medical center with 30-40 OR suites, that might not be the case. The anesthesiologist could technically still be in the OR, but not be considered immediately available if he's in the far reaches of the department.

Service location: Anesthesiologists work all over the hospital these days, whether it's in the main OR, outpatient services, radiology, labor and delivery, or trauma and step-down units. Pay close attention to where your physicians provide services because they might be spreading themselves too thin to still qualify as immediately available.

Patient condition: Most anesthesiologists typically have hands-on involvement with trickier cases, whether because of the procedure being performed (such as anesthesia during coronary artery bypass procedures [00562, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator]) or because of the patient's health (such as a patient qualifying  or P4, Patient with severe systemic disease that is a constant threat to life, because  of unstable angina, 411.1, Intermediate coronary syndrome). "Immediately available" comes into play for unanticipated responses the CRNA might not be qualified to handle. For example, the physician would get involved if the patient suddenly becomes hypotensive; the anesthesiologist determines whether to increase fluids, blood, nitrates, or beta blockers to treat the problem.

Key determinant: Consider how quickly the anesthesiologist could help the medically directed CRNA in the event of an emergency. If the anesthesiologist is away from the OR suite or outside the surgery department, is he "immediately available" to return if needed? If so, his work might still fit under the medical direction umbrella; if not, you might need to rethink his status.

Know How the Factors Affect Coding

The factors listed above won't change your code for the procedure itself, but can change the anesthesiologist's performance modifier " and his reimbursement. If the anesthesiologist personally performs a case, you know where he is for the entire procedure and report modifier AA (Anesthesia services performed personally by anesthesiologist) with the procedure code. The carrier pays him for the entire case.

Coding gets trickier when the anesthesiologist oversees other members of the team rather than personally performs cases. If he medically directs one CRNA, report modifier QY with the procedure code; if he directs from two to four anesthetists, report modifier QK instead. Physicians who medically direct cases split the procedure fee with the other anesthetist(s) involved.

Remember: Cases don't qualify for medical direction reporting simply because the anesthesiologist oversees a certain number of procedures. He must also meet all seven of CMS' medical direction criteria, listed in the box on page 67.

Note: If the anesthesiologist does not meet medical direction criteria, the CRNA might be able to report the case as non-medically directed with modifier QZ (CRNA service: without medical direction by a physician). However, many hospitals only credential CRNAs to work in conjunction with anesthesiologists, so know the hospital's policies before coding cases this way. "Know your local Medicare carrier's rules regarding medical direction and whether they allow the QZ modifier in this scenario," adds Sharon Donelli, CPC, CPC-H, administrative officer and coding/compliance director with Integrated Physicians Management Services in East Hartford, Ct.

Put Knowledge Into Practice

When it's time to write your group's guidelines for "immediately available," track how your physicians' services mesh with medical direction criteria. Always update your policy when there's a change in the services your anesthesiologists provide -- or a change in the location of these services. Even if nothing substantial changes, it's still a good idea to revisit your policy annually to tweak or revise it as necessary.

Final tip: Don't overlook your data administrator and/or IT department when educating your billing staff. "In mostpractices, the anesthesia billing software assigns concurrency modifiers," Donelli says. "The person responsible for programming the software must have a solid understanding of the concurrency rules. Always audit any programming changes to ensure claims go out with the correct modifier appended."