Anesthesia Coding Alert

Question: One of our anesthesiologists has seven concurrent cases for one day. What should I keep in mind when coding them?


North Carolina Subscriber

Answer: According to CMS, the medical direction ration is one to four concurrent cases (though this definition varies for some payers). The physician must also meet the seven steps of medical direction before you can report the cases as medical direction; otherwise you'll report them as medical supervision. This means the anesthesiologist was involved in more than four concurrent cases at a time or cases that don't meet the seven steps of medical direction (see box below for a list of these seven steps).
 
Append modifier -QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) or -QX (CRNA service: with medical direction by a physician) to medical direction cases. Report modifier -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) with medical supervision cases.

It's best to keep the 1:4 ratio, but many payers will give some type of reimbursement (usually reduced) for medical supervision.

Unfortunately, it is sometimes hard not to go over the 1:4 concurrency ratio. Medicaid and some commercial carriers (such as United Healthcare) do not reimburse for medical supervision cases, but some others do. Check with your local carriers about special guidelines for medical supervision.

Before coding a case as medical direction (by appending modifier -QK or -QX, as applicable), be sure the anesthesiologist meets all seven medical direction requirements:

1. Perform preanesthesia examination and evaluation.

2. Prescribe the anesthesia plan.

3. Take part personally in the most demanding procedures of the anesthesia plan, including emergence and induction.

4. Ensure that any procedures in the anesthesia plan that he doesn't perform are performed by a qualified anesthetist.

5. Monitor the course of the anesthesia administration at intervals.

6. Be physically present and available for immediate diagnosis and treatment of emergencies.

7. Provide the postanesthesia care indicated.

If the anesthesiologist does not meet all of these criteria for the case, you must report it as medical supervision instead of medical direction.