Anesthesia Coding Alert

Question: When our patients have cataract procedures, the anesthesiologist administers the eye block and the CRNA does the MAC. I've been billing the time for the eye blocks and not the 67500 code separately since it is inclusive to the MAC. I've been billing the MAC for these procedures using the Q modifiers and modifier AA for the eye block since it is done by the anesthesiologist (the anesthesiologist does the block for the next patient while the CRNA finishes up the prior patient). Here's how my claims look:

• 00142,QX,23,QS (for MAC)
• 00142,QY,23,QS (for MAC)
• 00142,AA,23,QS (for the eye block time)

I'm not sure if this is correct. Should the time for the eye block be included with the 00142,QY,23,QS even though the CRNA is not doing the eye block? Or should it be separate using the 00142,AA,23,QS?

Maryland Subscriber

Answer: First, understand that the claim example you provided is not correct. According to the National Correct Coding Initiative (NCCI), "A patient who undergoes a cataract extraction may require monitored anesthesia care. This may require administration of a sedative in conjunction with a peri/retrobulbar injection for regional block anesthesia. Subsequently, an interval of 30 minutes or more may transpire during which time the patient does not require monitoring by an anesthesia practitioner. After this period, monitoring will commence again for the cataract extraction and ultimately the patient will be released to the surgeon's care or to recovery. The time that may be reported would include the time for the monitoring during the block and during the procedure. The interval time and the recovery time are not included in the anesthesia time calculation. Also, if unusual services not bundled into the anesthesia service are required, the time spent delivering these services before anesthesia time begins or after it ends may not be included as reportable anesthesia time. However, if it is medically necessary for the anesthesia practitioner to continuously monitor the patient during the interval time and not perform any other service, the interval time may be included in the anesthesia time."

If your physician is medically directing the case on a one-to-one ratio (see modifier QY example above), the documentation should support the time spent with the patient to perform the retrobulbar block (discontinuous time) as well as medical direction.

The physician claim will include 00142 (Anesthesia for procedures on eye; lens surgery), modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist), and modifier QS (Monitored anesthesia care) plus the amount of documented anesthesia time. The CRNA claim will have 00142, modifier QX (CRNA service: with medical direction by a physician), modifier QS, and the documented anesthesia time.

Do not report 67500 (Retrobulbar injection; medication [separate procedure, does not include supply of medication]) or 00142 separately with modifiers AA (Anesthesia services performed personally by anesthesiologist), 23 (Unusual anesthesia), and QS as you suggested. Please refer to the back of your CPT® book for an explanation of the 23 modifier, which indicates unusual anesthesia. The 23 modifier does not apply to this described circumstance.