Anesthesia Coding Alert

Appending modifier AD will make a big difference to your bottom line.

Knowing whether to report an anesthesiologist’s case as medically directed or medically supervised can sometimes be tricky for even the most experienced coders – and can make a big difference in your practice’s bottom line. Refresh your memory on how to handle the situation by reviewing some basics about medical direction vs. medical supervision, plus several common scenarios.

Begin With Correct Direction/Supervision Classification

Your first step in determining whether to report medical direction or supervision lies in verifying the number of concurrent cases the anesthesiologist was involved in at the time. Your modifier choices that designate whether the anesthesiologist supervised or directed are:

• QY – Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
  
• QK – Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
  
• AD – Medical supervision by a physician; more than 4 concurrent anesthesia procedures.
  

Remember: Concurrent anesthesia procedures are those that overlap – even if only by one minute. The anesthesiologist shifts from medical direction to medical supervision once he oversees more than four concurrent anesthesia procedures. Medical supervision also applies if the anesthesiologist doesn’t meet all seven criteria for medical direction (see the box on page ____).

Reimbursement: If the anesthesiologist meets all criteria for providing medical direction, each procedure he directs pays 100 percent (which is split 50/50 between the physician and CRNA). Payment for medical supervision is normally based on three units (plus one additional unit if the anesthesiologist participated in induction) for the physician and 50 percent payment for the CRNA.

Tip: Let the payer adjust the number of units for the anesthesiologist instead of doing it yourself. Check your local guidelines for specific instructions and know that Medicare will reduce the units for you when applicable.

Include the appropriate modifier for the physician’s medical direction or supervision on each claim the anesthesiologist files.

Situation 1: Anesthesiologist and CRNA Work Together

Scenario: Your providers offer kyphoplasty in the office setting. The physician performs the kyphoplasty and the CRNA administers anesthesia.

Coding: The anesthesiologist will report the correct procedure code(s) for the kyphoplasty (22523-+22525) and the CRNA will report the anesthesia with 01936 (Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic). You will not report a medical direction/supervision modifier for the anesthesiologist because a physician cannot personally perform a procedure while medically directing or supervising a CRNA. You should, however, append modifier QZ (CRNA service: without medical direction by a physician) to the CRNA’s claim.

Situation 2: Unexpected Cases Added to the Mix

Scenario: Four CRNAs from your group are working on separate cases under the anesthesiologist’s medical direction. An emergency patient comes in, and the anesthesiologist takes the case. He is no longer available to medically direct the CRNAs.

Coding: CMS states that a medically directing anesthesiologist can perform certain other services concurrently and retain his or her medical direction status. One example is “Addressing an emergency of short duration in the immediate area.”

The answer for this situation depends on whether the anesthesiologist’s involvement in the emergency case was of “short duration” and whether he remained in the immediate area. If so, the anesthesiologist is still medically directing the CRNA cases and should submit his participation in the cases with modifier QK. Report each CRNA’s case with modifier QX (CRNA service: with medical direction by a physician).

If the emergency case took more of the anesthesiologist’s time and he is not available to the medically directed CRNAs, he can no longer be considered as medically directing the CRNAs. He cannot bill for any of his involvement in those cases. Submit the claims for the CRNAs with modifier QZ (CRNA service: without medical direction by a physician).

Situation 3: Filing Supervision or Direction Claims With Multiple Payers

Scenario: The anesthesiologist medically directs three cases where one payer is Medicare and the others are private insurers.

Coding: When it’s time to calculate concurrencies, all payers’ cases go into the mix – not just Medicare. Include every case when determining whether to report the anesthesiologist’s service as medical direction or medical supervision, even if you might not report the concurrency modifiers to all payers.