Anesthesia Coding Alert

Question: How are student registered nurse anesthetist (SRNA) teaching cases reported? Does payment vary based on physician vs. CRNA providing instruction?

Maine Subscriber

Answer: When an anesthesiologist performs the entire anesthesia service alone or is continuously involved in a single case with an SRNA, bill the case as personally performed using modifier AA (Anesthesia services performed personally by anesthesiologist).

Although the Centers for Medicare & Medicaid Services (CMS) does not provide a lot of information about physicians teaching SRNAs, there is a full section on payment for anesthesia services furnished by a teaching Certified Registered Nurse Anesthetist (CRNA) in the Medicare Claims Processing Manual.

Surprisingly, CMS allows a CRNA (not medically directed by an anesthesiologist) 100 percent of up to two concurrent cases when documented appropriately and reported with modifier QZ (Crna service: without medical direction by a physician). However, when an anesthesiologist directs two or more teaching cases with a student nurse, each is reported with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures …) and is reimbursed at 50 percent.

Per the Medicare manual, “The requirements for payment at the medically directed rate also apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologist’s assistant, intern or resident).”

Note: Modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) only applies to medical residents; do not append it to teaching cases involving student nurses.