Anesthesia Coding Alert

Question: Our anesthesiologist provided medical direction to a CRNA involved in a several-hour trauma case on a Medicare patient. What documentation should I look for when determining whether the second CRNA on duty assisted with the case? The anesthesiologist was not involved with any concurrent cases.

Texas Subscriber

Answer: It's not unusual for two providers to be fully involved in a trauma case. Medicare will typically pay for two fully involved providers, according to their Texas guidelines - assuming you can prove medical necessity.

The guidelines state, "In unusual circumstances, when it is medically necessary for both the CRNA and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed."

Submit documentation to support each provider's involvement. Append modifier -QY(Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) to the physician's claim and modifier -QX (CRNA service: with medical direction by a physician) to the CRNA's claim.

Check the record's documentation of the second CRNA's involvement before billing for it. If the two CRNAs were involved in the case at different times, append modifier -QYto the anesthesiologist's claim and modifier -QX to each CRNA's claim.

The unusual angle with this situation is if the anesthesiologist medically directed two CRNAs on the same case. Why was this necessary? Did the physician keep separate records with the presence requirement met on each? His documentation determines how you should code the case.

Clear documentation might allow you to report the physician's services with modifier -QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) and each CRNA's service with modifier -QX (CRNA service: with medical direction by a physician). This scenario reimburses the physician at 100 percent and one CRNA at 50 percent. You might be entitled to the remaining 50 percent reimbursement for CRNAservice if the documentation supports medical necessity.

-- You Be the Coder and Reader Questions were answered by Terri Celestino, CPC, an anesthesia coder with Tejas Anesthesia in San Antonio.