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Anesthesia Coding Alert

Reader Question:

Base Fee Includes Pre-Op Assessment

Published on Tue Oct 17, 2006

Question: Our CRNA meets with patients prior to surgery to ask about allergies or other health issues, to check the patient's airway and to explain the process. Can I bill this as part of the CRNA's face-to-face time? She documents start and stop times for the evaluation, and again for the actual procedure.


New Mexico Subscriber
  

Answer: If the CRNA is non-medically directed (meaning you report her service with modifier QZ, CRNA service: without medical direction by a physician), you cannot bill separately for her time because these questions are part of the preoperative visit included in the procedure's base fee.
 
If the CRNA is medically directed (which you report with modifier QX, CRNA service: with medical direction by a physician), she can collect data and co-sign the pre-op assessment. One of your group's physicians, however, must document that he performed the examination and evaluation as the first step of medical direction.
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