Anesthesia Coding Alert

Hint: Keep all your clocks in sync to ensure your times match.

When providing anesthesia services, anesthesiologists have three options for their involvement in a particular case: personally perform, medically supervise, or medically direct.

Cases that can be categorized as personally performed are the easiest to recognize and the simplest to report. This means the anesthesiologist administered the anesthesia and was solely responsible for the patient from the time of induction through emergence and hand-off to the post-anesthesia care team. Unless working with two residents or one-to-one with a student nurse, no other anesthesia providers are involved, so you submit the full claim under the anesthesiologist’s name and append modifier AA (Anesthesia services performed personally by anesthesiologist).

When a case involves both the anesthesiologist and another anesthesia provider (such as a CRNA and anesthesia assistant), correctly reporting the case gets a bit more involved. Keep these guidelines in mind when the anesthesiologist’s participation shifts from personal performance to either medical direction or medical supervision.

Guideline 1: Watch the Requirements for Medical Direction

The anesthesiologist is allowed to be involved in more than one concurrent case if the physician is not personally performing the anesthesia. Medical direction earns higher reimbursement than medical supervision, but it also involves meeting stricter requirements before it can be reported.

Basic definition: Medical direction occurs when an anesthesiologist directs the concurrent delivery of anesthesia care by up to four nonphysician anesthesia providers (excluding teaching cases) — and when the anesthesiologist meets seven billing requirements associated with each of those cases.

These seven documentation requirements for medical direction are:

• Perform a pre-anesthetic examination and evaluation
• Prescribe the anesthesia plan
• Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence
• Ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform
• Monitor the course of anesthesia administration at frequent intervals
• Remain physically present for all key and critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies
• Provide post-anesthesia care as indicated

Plus: It’s also important to note that the Centers for Medicare & Medicaid Services (CMS) has identified several services as “permissible exceptions” to the medical direction rules, meaning that the anesthesiologist is allowed to perform these services while still medically directing other cases, points out Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

For example, one of the most important exceptions is administration of labor epidurals. The anesthesiologist can medically direct a case and leave the area to administer an epidural for the purposes of easing labor pain, as long as they are still close enough to return if needed, which will depend on the facility layout.

Other exceptions can include receiving the next surgical patient, checking or discharging patients in the recovery room, handling scheduling matters, addressing an emergency of short duration in the immediate area, or periodically monitoring an obstetrical patient.

Caveat: Thorough documentation of any care you’re reporting as an exception to medical direction is critical to receiving and retaining payment.

How to report it: Designate medical direction by the anesthesiologist based on the number of concurrent cases. Append either modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist) or modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals).

Tip: Check with your state Medicare Administrative Contractor to see if they publish guidance for other exceptions. For example, in Anesthesia Frequently Asked Questions (FAQs), Novitas indicates “An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions, central venous catheter insertions, pulmonary artery catheter insertions, and epidural, spinal, and peripheral nerve blocks) performed in an area immediately available to the operating room when performance of such services does not prevent him/her from being immediately available to respond to the needs of surgical patients.”

Guideline 2: Even a Minute Makes a Difference in Direction

The anesthesiologist’s involvement in cases shifts from medical direction to medical supervision when one of two scenarios occurs:

1. The number of concurrent cases the anesthesiologist is supervising goes beyond four
2. The anesthesiologist is unable to perform all seven required services of medical direction for each concurrent anesthesia procedure

Overstepping the concurrency guideline is the most common reason for shifting from direction to supervision — adding a fifth concurrent case to the mix for as little as a minute is all it takes to change the designation.

How to report it: There are no specific requirements for the anesthesiologist to provide hands-on care for medically supervised cases; instead, the physician is available to help with any of the concurrent cases. Any cases you submit for an anesthesiologist as medical supervision must include the performance modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures).

If your practice is in a Noridian covered area, their anesthesia specialty page specifically states that “Medical supervision occurs when the anesthesiologist is involved in more than four concurrent cases and when not all seven services under medical direction are performed.”

End result: Most insurers reduce the anesthesiologist’s payment when cases are reported as medical supervision rather than medical direction. For example, Medicare pays the anesthesiologist for only three units for each concurrent supervised case (unless the physician was present on induction, which adds one more unit to a general anesthesia case when documented).

Final tip: Rules can vary between payers and according to the facility (such as in teaching hospitals where residents are involved in patient care). Verify guidelines with the payer in question and check to see whether your state Medicare Administrative Contractor has published Frequently Asked Questions (FAQS) for medical direction. Interpretation of broken medical direction varies from state to state.