Anesthesia Coding Alert

Question: A CRNA administered a regional Bier block during excision of a lesion on the patient's forehead. The CRNA wrote "MAC" (monitored anesthesia care) beside the Bier block notation. I originally submitted modifiers -G8, -QZ and -QS with the claim. Medicare rejected the claim, so what should I report instead?

Pennsylvania Subscriber

Answer: Begin with verifying the lesion's location, then determining whether the CRNA administered a Bier block or MAC. Using a Bier block for a forehead lesion would be highly unlikely, so check whether the lesion was on the patient's forearm instead of the forehead.

If it was a forearm lesion with a Bier block, code with 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]). If the physician treated a forehead lesion, report 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified).

The CRNA probably administered MAC for the case, so check the patient's history and physical (H&P) to find a diagnosis that supports MAC necessity. Most carriers include 00300 in their lists of procedures that support MAC, so having this paperwork could help justify its use. Verify that the diagnosis also supports medical necessity, such as 173.3 (Other malignant neoplasm of skin; skin of other and unspecified parts of face).

Also check your modifiers. Appending modifier -QZ (CRNA service: without medical direction by a physician) indicates that an anesthesiologist did not medically direct the CRNA during the case. If she was medically directed, report modifier -QX (CRNA service: with medical direction by a physician) or modifier -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) instead, depending on the situation.

If the CRNA administered MAC, also report modifier -QS (Monitored anesthesia care service). However, the case does not merit modifier -G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure), so delete it from the claim.