Anesthesia Coding Alert

Let payers reduce your case units instead of handling it yourself.

A prime factor in determining whether you can report your anesthesiologist's work as medical direction or medical supervision depends on concurrency -- the number of cases she oversaw or assisted with at the same time. Refine your concurrency coding by remembering some do's and don'ts.

Do Add --AD, But Don't Adjust Units

When the anesthesiologist medically directs one CRNA, append modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) to the physician's claim. Once the number of concurrent cases the anesthesiologist oversees rises, you can report a maximum of four concurrent cases as medical direction with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). Teaching facilities should keep in mind the Residency Review Committee limits the teaching ratio to one teaching anesthesiologist to two residents and/or student nurse anesthetists.

If the anesthesiologist's concurrent case load passes a ratio of four, the cases may move into medical supervision territory, depending on local Medicare Administrative Contractor guidance. Include modifier AD (Medical supervision by a physician; more than 4 concurrent anesthesia procedures) with each claim when the anesthesiologist reports more than four concurrent cases, says Cindy Hinton, CPC, CHCC, with Advanced Coding Solutions in Whitehouse, Tenn.

Units drop: Payers might allow only three base units per procedure when the anesthesiologist is involved in more than four procedures concurrently or when he or she performs other services while directing the concurrent procedures. The carrier might recognize an additional time unit if the physician can document that he or she was present at induction.

Because payers might handle the number of base units differently, don't automatically report a maximum of three units for each medically supervised, concurrent case. Check your local guidelines for specific instructions and know that Medicare will reduce the units for you when applicable -- you don't need to do it yourself.

Do Keep Concurrencies Across Payers

When it's time to calculate concurrencies, all payers' cases go into the mix -- not just Medicare.

For example, the anesthesiologist might participate in two concurrent cases where one payer is Medicare and the other is Blue Cross. The concurrencies count for all cases, even if you might not report the concurrency modifiers to all payers. Because of this, always check every claim for concurrency, regardless of the patient's insurer.

Bonus tip: Although a medically directing physician can overlap his or her time between cases, times for the medically directed CRNA (designated with modifier QX, CRNA service: with medical direction by a physician) should never overlap. The CRNA cannot be involved with more than one case at a time.

Don't Forget Behind-the-Scenes Staff

Don't overlook your data administrator and/or IT department when educating your billing staff, experts say.

Here's why: In many practices, the anesthesia billing software assigns concurrency modifiers. The person responsible for programming the software must have a solid understanding of the concurrency rules to be sure the program calculates correctly. Always audit any programming changes to ensure claims go out with the correct modifier appended.