Anesthesia Coding Alert

Experts say documentation of time is a common – but fixable – error. 

Your anesthesiologists may prefer to work on cases that qualify as personally performed or medically directed because they can provide more focused care -- plus reporting that way helps your practice’s bottom line. When you report medical supervision, however, your coding and pay change, so brush up on what you need to know about submitting claims for the different scenarios.

Follow These Guidelines for Personally Performed and Medical Direction 

The simplest cases to code are when your anesthesiologist personally performs the service. You report the applicable anesthesia code and time units, append modifier AA (Anesthesia services performed personally by anesthesiologist) to the CPT® code, and receive full reimbursement. 

Your next best option from a reimbursement standpoint is medical direction, which you report with either modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) or modifier QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals). If you’re also filing on behalf of the CRNA, you append modifier QX (CRNA service: with medical direction by a physician) to that claim. 

The first guideline for medical direction is that the anesthesiologist must be directing four or fewer concurrent cases before you can report them as directed. Then he must also meet CMS’ seven rules for medical direction: 

1. Perform a preoperative exam and evaluation.
2. Prescribe the anesthesia plan.
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence (if applicable).
4. Ensure that any procedures in the anesthesia plan are performed by a qualified anesthetist.
5. Monitor – and document – the course of the anesthesia administration at frequent intervals; (remember that CMS does not define “frequency”).
6. Be physically present and available for immediate diagnosis and treatment of emergencies.
7. Provide the post-anesthesia care indicated.

Split Fees for Medical Supervision

If the anesthesiologist fails to meet any of the medical direction criteria (or if the case load climbs to five or more concurrent cases), you must report each case during that time frame as medically supervised (by appending modifier AD, Medical supervision by a physician: more than four concurrent anesthesia procedures) instead of medically directed. The exception is when a Medicare Administrative Contractor has published information allowing the CRNA to report modifier QZ (CRNA service: without medical direction by a physician) for cases classified as failed medical direction. 

Sometimes shifting gears from medical direction to medical supervision can’t be helped, but practices try to avoid it for a combination of reasons. One of the main reasons involves the bottom line because you can see a big difference in reimbursement for supervision versus direction. 

Red flag: With medical supervision cases, the physician can only bill for 3 base units and no time. The CRNA involved with the case can bill for the actual base units and time units, but is only paid at 50 percent, according to medical direction rules. 

“The physician is eligible for reimbursement of three base units unless he or she was present for induction, which can increase that number to four,” explains Cindy Hinton, CPC, CCP, CHCC, owner of Advanced Coding Solutions, LLC, in Franklin, Tn. “The AD modifier automatically signals the reduction and will occur at the payer level even if the claim is submitted with full base/time units.”  

Pay attention: “Remember, monitored anesthesia care (MAC) and regional anesthesia do not have an ‘induction’ period,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “Only general anesthesia has an induction period that you need to watch in terms of medical direction criteria.” 

“Also, just to be clear, it’s worth noting that under medical supervision, all concurrent cases will be time exempt,” Hinton adds. “In other words, all time units are lost.”

Tip: If your state, practice and hospital allow it, some practices know that they do better to bill a QZ (CRNA service: without medical direction by a physician) for the CRNA working alone. That way the CRNA will be paid at 100 percent for the case. 

Example 1: If your group provides anesthesia for a two-hour spinal procedure with instrumentation, this is how you would be paid if your fee is $50 per unit (15-minute units, for a total of 8 time units): 

Supervision MD $150    CRNA $525        Total $675 

CRNA alone $1,050

Big picture: Many practices don’t have many situations that require modifier AD, so it has a minimal impact on the bottom line in general. However, shifting to medical supervision instead of direction can have a large impact on individual cases. 

Example 2: If an anesthesiologist medically directs a case with a high number of base units (such as 00406, Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedure on breast with an internal mammary node dissection, which is 13 units) and the service becomes medical supervision, the anesthesiologist can only be reimbursed for 3 base units (or 4 units if his participation in induction is documented). This is a loss of 9 or 10 units on a single case – which might not be a large discount for a single case, but would quickly mount if it happens often.

Final point: “While there are a number of reasons a case can go from medical direction to medical supervision, one common and highly avoidable error is in the documentation of time,” Hinton says. “Providers need to be highly aware that accurately documenting start and stop time is critical. The overlap of just one minute can make the difference in medical direction versus medical supervision. It can be a very costly oversight!”

Knowing whether to bill your anesthesiologist’s cases as medically directed or supervised can be quite tricky,  especially because medical-direction guidelines are chock full of “gray areas.” But by working with your physicians and carriers to understand terms such as “an emergency of short duration,” you can be sure your claims -- and your reimbursement -- are accurate.