Anesthesia Coding Alert

Question: Anesthesiologist A medically directed a CRNA during the first portion of a Medicare patient's case (he wasn't medically directing any other staff). Anesthesiologist B relieved Anesthesiologist A. The CRNA also left, leaving Anesthesiologist B alone for the remainder of the case. How should I code the direction?

Texas Subscriber

Answer: The answer will depend on whether your Medicare Administrative Contractor publishes Frequently Asked Questions. For example, if this is a Railroad Medicare patient, FAQs were published in June 2011 indicating that you should code based on how the case began. Once a case starts, it remains in that category despite changes in staffing or direction. In your scenario, report the case as medically directed for the entire time.

Here's how: Append modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) to your physician's code, and modifier QX (CRNA service: with medical direction by a physician) to the CRNA's code. Although two anesthesiologists helped with the case, billing the case under Anesthesiologist A's provider number is easiest (and some billing software won't let you enter multiple physicians for a case). If the physicians want separate billings, assign the procedure code to Anesthesiologist A with his time, and report the time for Anesthesiologist B separately.

Details: Be sure to include notes regarding the time for physician relief when Anesthesiologist B became involved. Although you may not need this information on the claim, it is important should auditors review the chart for malpractice or concurrency issues later.

Hint: Check whether your Medicare Administrative Contractor has published FAQs that might help when filing these types of claims.