Anesthesia Coding Alert

Question: Our anesthesiologist initiated a surgery case for a Medicare patient. She left after two hours and another attending anesthesiologist took over the case for the remainder of the surgery. Later, a student nurse inserted an arterial line without a teaching physician or CRNA being “hands on.” Is the service billable?

Ohio Subscriber

Answer: No, the service is not billable. Medicare will deny payment for an arterial line when the only person documented as providing the procedure was a nurse.

Reasoning: This CMS stance likely comes from CR 6706: “… the payment policy for the teaching CRNA in the single student nurse anesthetist case remains unchanged for services furnished on or after January 1, 2010; however, under MIPPA Section 139, when involved with two concurrent cases with student nurse anesthetists (on or after this date), he or she can be paid at the regular fee schedule rate for each case. To bill the base units for each of the two cases, the teaching CRNA must be present with the student during the pre- and post-anesthesia care for each case. In addition, while he or she can decide how to allocate time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient’s health status and other factors; the CRNA must continue to devote all of his or her time to the two concurrent student nurse anesthetist cases and not be involved in other anesthesia cases. The teaching CRNA may bill usual anesthesia time for each anesthesia case. For services furnished on or after January 1, 2010, the teaching CRNA should report these cases with the QZ [CRNA service: without medical direction by a physician] modifier as described above. You should also remember that the teaching CRNA’s medical record documentation in these cases must be sufficient to support the payment of the fee and be available for review upon request. Additionally, be aware that no payment is made under Part B for the service provided by a student nurse anesthetist.”

Final point: Medicare also states that, “The required teaching documentation should be clear to anyone reviewing the record – whether electronic or paper. Signatures alone do not indicate who did what, especially with ancillary services such as arterial line placement. Have the notes to back up your claim.”