Anesthesia Coding Alert

Question: I am new to anesthesia billing and still trying to understand some of the modifier, especially QX versus QZ. Our provider has a CRNA staffing company that provides the anesthesia while the physician performs the procedure. Would this scenario fall under QX when billing for the CRNA?

Rhode Island Subscriber

Answer: The CRNA modifiers are QZ, which is used when the CRNA is performing anesthesia services without medical direction, and QX, which is used when the CRNA is being medically directed by an anesthesiologist.

When you say the physician is performing the procedure, we are assuming you mean the surgeon, and the CRNA is providing the anesthesia service. If the CRNA is not being medically directed by an anesthesiologist (as in this situation), then you will submit his or her charge with the QZ modifier (CRNA service: without medical direction by a physician).

Terminology: Medical direction occurs when an anesthesiologist is involved in and physically present at one, two, three, or four concurrent procedures. The American Society of Anesthesiologists outlines seven criteria that must be met before you can report a case as medical direction instead of medical supervision. The anesthesiologist must:

1. Perform a pre-anesthesia examination and evaluation
2. Prescribe an anesthesia plan
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence
4. Ensure that any procedure in the plan that he or she does not perform is performed by a qualified anesthetist
5. Monitor the course of anesthesia administration at intervals
6. Remain physically present and available for immediate diagnosis and treatment of emergencies
7. Provide the indicated post-anesthesia care.

If the anesthesiologist does not meet all of these criteria and/or if the case load goes beyond four concurrent cases, you report the service as medical supervision instead of direction.