Anesthesia Coding Alert

CRNA role is another key to coding success

When both a CRNA and an anesthesiologist work together on an anesthesia team, your reimbursement depends on which modifier you assign. A few simple rules can help you determine the best option.

Adjust Reimbursement Expectations for CRNA Involvement

When an anesthesia team consists of an anesthesiologist and a CRNA, reimbursement depends on the surgery's circumstances and how the procedure is coded, says Cecelia McWhorter, BA, CPC, a coder with EmPhysis Medical Management Ltd. in Oklahoma City.
 
Prior to 1998, if both an anesthesiologist and an anesthetist were involved in a single case, some local Medicare carriers and private insurers considered the service to be personally performed by the anesthesiologist (-AA), says anesthesiologist Scott Groudine, MD, of Albany, N.Y. If you filed a claim with modifier -AA appended to the anesthesiologist's service code, the carrier would pay the anesthesiologist as if he or she personally performed it, instead of generating or paying a CRNA bill. This was because modifier -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) did not yet exist. Now, however, you should append modifier -QY to the claim to indicate both the physician's and CRNA's involvement.
 
Medicare now reimburses both practitioners for the service. According to the policy of HGSAdministrators (a Pennsylvania Medicare carrier), "In unusual circumstances (i.e., complicated trauma case) in which it is medically necessary for both the CRNA and the anesthesiologist to be involved completely and fully in a single case, full payment to each can be made if documentation is submitted by both the CRNA and the anesthesiologist to support payment of the full fee for each."
 
The policy also states that the physician should append modifier -AA to the appropriate anesthesia code. The CRNA should append modifier -QZ (CRNA service: without medical direction by a physician) to the anesthesia code. Modifier -QZ tells the carrier that both providers were fully engaged in the patient's care, distinguishing it from a case with the anesthesiologist and CRNA working in a care-team mode. The anesthesiologist and CRNA must each provide adequate documentation to demonstrate medical necessity for their services, including the operative and anesthesia reports.
 
The insurer should pay the anesthesiologist and CRNA each 50 percent of the reimbursement for medically directed cases. You must meet certain "unusual circumstances" criteria (such as massive bleeding, shock or impending death), before your insurer will pay both the anesthesiologist and CRNA as two separate medically necessary providers.
 
Medicare may reimburse both the anesthetist and the physician in the following situations when both providers' services are medically necessary: