Anesthesia Coding Alert

States continue to opt out of CRNA supervision regulation.

If you code for CRNA services, be sure you know your state's latest stance on whether CRNAs can administer anesthesia without medical supervision.

Why: In November 2001, CMS established an option for certified registered nurse anesthetists (CRNAs) to be exempt requiring physician supervision when administering anesthesia. Sixteen states have opted out of the requirement to date, with the most recent being California in October 2010. States opting out include:

• California
• Colorado
• Iowa
• Nebraska
• Idaho
• Minnesota
• New Hampshire
• New Mexico
• Kansas
• North Dakota
• Washington
• Alaska
• Oregon
• Montana
• South Dakota
• Wisconsin.

"If the state opts out, then CRNAs may perform services without oversight of an anesthesiologist as long as their malpractice coverage and hospital delineation of privileges allows," explains Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

When you submit claims for CRNA service without medical direction, append modifier QZ (CRNA service; without medical direction by a physician) to the anesthesia code. Otherwise, include the applicable modifiers on both the CRNA's and anesthesiologist's claims for medical direction:

• QX -- CRNA service; with medical direction by a physician
• QK -- Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
• QY -- Medical direction of one CRNA by an anesthesiologist.

Local Guidelines Can Surpass Federal Rules

The CMS final rule in November 2001 followed years of deliberation and comment from the public and healthcare community. The ruling held up the federal requirement that a physician supervise CRNAs when caring for Medicare or Medicaid patients in hospitals, critical access hospitals, and ambulatory surgical centers. However, a governor can exempt any institution or the entire state from the supervision requirement if the action is determined to be in the best interest of the state's citizens. The governor must consult with state's boards of medicine and nursing (or their equivalents) and verify that the state's laws and regulations allow independent CRNA practice.

States and hospitals are free to establish additional standards for professional practice and oversight as they deem necessary. Because of that, state regulations can be more stringent than federal requirements.

Example: Some states give anesthesiologists the right to perform brain surgery, but hospitals won't credential them to do so on a local level. In addition, a hospital must require physician supervision of anesthesia in order to participate with Medicare.