Anesthesia Coding Alert

Question: How do insurers reimburse for out-of-network claims when the case involves both CRNA work and physician medical supervision? Is it split 50/50 as in Medicare?

Maryland Subscriber

Answer: The answer depends on your location and the payer in question. While many Medicare payers do reimburse at 50/50 for cases involving a CRNA and physician supervision, other don't. For example, the Indiana Medicaid website states, "Certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs) are reimbursed at 60% of the allowable physician rate. Medical direction of two, three, or four anesthesia procedures is reported using modifier QK and is reimbursed at 30% of the allowable physician rate."

The allowed payment will also vary according to whether the anesthesiologist was medically directing the case or medically supervising. Some insurers won't pay for both providers' services when the physician is medically directing.

If your contract with the payer doesn't state how these cases are handled, consider adding it the next time you negotiate. In the meantime, submit the claim and wait to see if it's approved or denied. If you receive a denial you can appeal with documentation showing the individual providers' involvement and pointing out the different modifiers used on the claim (such as modifier QX, CRNA service: with medical direction by a physician and modifier QY, Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist).