Anesthesia Coding Alert

Different states can have different reporting requirements.

The current HCPCS manual includes several modifiers that you can sometimes append to claims for CRNA services. One of the most common is modifier QZ (CRNA service: without medical direction by a physician). If you’re considering adding it to a claim or wonder how to correctly report it, read on for several scenarios that can help.

Scenario 1: Supervision by a Non-anesthesiologist

Question: I code for an ASC that employs CRNAs. The ASC is in New York, which requires all CRNAs to be supervised. The state requires the supervision be by a physician, but does not specify which type of physician it must be. In this center, GI physicians performing endoscopies supervise the CRNAs. They are not directed by an anesthesiologist. Is it still appropriate for us to append modifier QZ to the CRNA claims even though the GI physician is taking responsibility instead of an anesthesiologist?

Answer: Yes, you should still include modifier QZ on the CRNA’s claims.

Rationale: The CRNA is being supervised rather than medically directed, which is one criteria for modifier QZ. In addition, if you bill the CRNA’s claim with modifier QX (CRNA service: with medical direction by a physician), the payer will look for an accompanying claim with either modifier 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) for the anesthesiologist’s service. That isn’t possible in this situation because you aren’t coding for an anesthesiologist and the GI physician cannot submit claims for both anesthesia and the procedure.

Scenario 2: Partial Supervision of CRNA

Question: I have a case where an anesthesiologist is supervising a CRNA for only the beginning of the procedure. Would the CRNA get the QX or QZ modifier? It seems that both technically apply.

Answer: You can only bill for supervision if the supervision lasted the entire duration of the procedure. Because of this, modifier QZ is more appropriate than QX (CRNA service: with medical direction by a physician).

Also: You classify this as supervision, but the QX and QZ modifiers only apply to cases that qualify for medical direction. Verify that the anesthesiologist met all the criteria for the case to be considered medical direction before you submit either QX or QZ. If the case doesn’t meet all the criteria, it counts as medical supervision.

For a more definitive answer, check your payer’s stance on reporting the CRNA modifiers.

Scenario 3: Distinguishing Supervision From Direction

Question: I am new to anesthesia billing and still trying to understand some of the modifier, especially QX versus QZ. Our provider has a CRNA staffing company that provides the anesthesia while the physician performs the procedure. Would this scenario fall under QX when billing for the CRNA?

Answer: The CRNA modifiers are QZ, which is used when the CRNA is performing anesthesia services without medical direction, and QX, which is used when the CRNA is being medically directed by an anesthesiologist.

When you say the physician is performing the procedure, we are assuming you mean the surgeon, and the CRNA is providing the anesthesia service. If the CRNA is not being medically directed by an anesthesiologist (as in this situation), then you will submit his or her charge with the QZ modifier (CRNA service: without medical direction by a physician).

Terminology: Medical direction occurs when an anesthesiologist is involved in and physically present at one, two, three, or four concurrent procedures. The American Society of Anesthesiologists outlines seven criteria that must be met before you can report a case as medical direction instead of medical supervision. The anesthesiologist must:

1. Perform a pre-anesthesia examination and evaluation
2. Prescribe an anesthesia plan
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence
4. Ensure that any procedure in the plan that he or she does not perform is performed by a qualified anesthetist
5. Monitor the course of anesthesia administration at intervals
6. Remain physically present and available for immediate diagnosis and treatment of emergencies
7. Provide the indicated post-anesthesia care.

If the anesthesiologist does not meet all of these criteria and/or if the case load goes beyond four concurrent cases, you report the service as medical supervision instead of medical direction.

Also keep in mind: There is not a national policy for how payers should pay for the services associated with incomplete medical direction. “Reimbursement for these cases is determined by the local carrier -- it can vary from case to case,” says Cindy Lane, CPC, CHCC, with Advanced Coding Solutions in Whitehouse, Tenn.

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).

Play it safe: Checking with your carriers to make sure that they recognize all of the HCPCS modifiers you plan to use in your claim is always a good idea. Your reporting method should always be based on on the exact circumstances of the case.