Anesthesia Coding Alert

After four years of deliberation and comment from the public and health care community, CMS published its final rule regarding physician supervision of CRNAs in late November, effective immediately. It retained the long-standing federal requirement that a physician supervise nurse anesthetists when caring for Medicare or Medicaid patients in hospitals, critical access hospitals and ambulatory surgical centers.
 
However, a governor can exempt any institution(s) or the entire state from the federal supervision requirement if such an action is determined to be in the best interest of the state's citizens. This type of exemption can only be obtained after the governor consults with the state's boards of medicine and nursing (or their equivalents) and verifies that state laws and regulations allow independent CRNA practice. There is no requirement for public hearing or citizens' input. An exemption to the federal regulations takes place immediately after the governor notifies CMS that the above conditions were met and that his state wishes to "opt out" of the regulation. If the local situation changes later, such as a new governor or public reaction that dictate a change, the governor may notify CMS that his state is "opting in" again.
 
States and hospitals are free to establish additional standards for professional practice and oversight as they deem necessary. In that case, state regulations can always be more demanding than federal requirements.
 
"Regardless of what the final ruling was, California law requires that all CRNAs be supervised or directed," says Barbara Johnson, CPC, MPC, professional coder with Loma Linda University Anesthesiology Medical Group in Loma Linda, Calif. "Even if the ruling had established more lenient guidelines, California practitioners would still need to be supervised. The same situation applies in other states as well, such as New York." 

"You could also run into the issue of contracts between hospitals and anesthesiologists stating that CRNAs cannot work unsupervised or non-medically directed," she adds. "That's another situation where any changes to the existing rule would have been overshadowed by local guidelines."
 
Many practitioners believe that a high level of local control is good, and that it helps ensure better care for patients. For example, most states currently give anesthesiologists the right to perform brain surgery, but most hospitals on the local level will not credential them to do so. Because of the flexibility offered by more strict standards locally, the majority of Americans receive safe care.
 
Physician supervision of anesthesia care is a condition of Medicare participation by a hospital. CRNA modifier -QX (CRNA service: with medical direction by a physician) and physician modifiers -QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) and -QY (medical direction of one CRNA by an anesthesiologist) are used to report anesthesia services provided by a CRNA and anesthesiologist working together as part of an anesthesia care team. Practitioners in states that allow nurse anesthetists to practice without physician supervision can also code services with modifier -QZ (CRNA service without medical direction by a physician). 
 
Coding depends on the specific situation of the providers and the state regulations for CRNA supervision. Don McLeod of the CMS public affairs office points out that states do not have to obtain formal approval from CMS to establish stricter guidelines than the federal ruling. The governor of an individual state can work with local groups to set other regulations that may work better for their area. Will the supervision guidelines continue to be discussed at the state level? McLeod said in November that the regulation is still too new to forecast potential actions.
 
What does this mean for anesthesia providers and coders? The most important step for these groups is to determine their state and local governing body requirements regarding physician supervision of CRNAs so cases can be conducted legally and coded appropriately.