Medicare Compliance & Reimbursement

Hint: Final determination of what constitutes medical direction can vary.

When your anesthesiologist hasn’t met all seven criteria required to report his services as medical direction, this “incomplete” medical direction can present coding challenges. One key is knowing when to use which modifier to avert a claim denial. Let these three expert tips guide your way.

1. Start With Your Local Carrier

The Centers for Medicare and Medicaid Services (CMS) does not have a national-level policy for incomplete medical direction. Instead, it has directed the local carriers to address this issue case by case. That means the final determination of what constitutes medical direction can vary, depending on the circumstances (especially for some of the more nebulous guidelines, such as remaining “physically present and available”).

But, in general, the CRNA could submit the claim by using modifier QZ (CRNA service: without medical direction by a physician), or the physician might report the procedure using modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) if the concurrent case load surpasses the maximum of three allowed for medical direction.

Caution: If the anesthesiologist reports modifier AD, the CRNA should report modifier QX (CRNA service: with medical direction by a physician) instead of QZ. If you submit modifier QZ, the carrier will erroneously pay 100 percent of the CRNA’s services in addition to the physician reimbursement — leading to an inadvertent over payment for services.

Smart move: Be clear about who employs the CRNA to ensure that the proper entity files the claim. If the group employs the CRNA, it may file the CRNA services with its services (just keep in mind that the group doesn’t necessarily need to report these modifiers). If the group doesn’t employ the CRNA, the payer usually pays the first claim filed and rejects the second claim.

Play it safe: Check with your payers to verify that they recognize all of the HCPCS modifiers you plan to include in your claim. Your reporting method may depend on the exact circumstances that rendered medical direction incomplete.

2. Save Headaches by Explaining Circumstances

Submitting a claim that clearly indicates the portion of the case that met medical direction — as well as the portion that didn’t — allows the payer to make a decision based on the circumstances for your specific claim. In some cases, carriers will still allow reimbursement for the entire claim based on medical direction. Regardless of the appropriate reporting method for your case, always remember that you must consider the physician’s time involved when reporting concurrent cases.

Heads up: By submitting a claim for the CRNA with modifier QZ, you might have eliminated the physician from the claims process, experts warn. But you still have to account for his or her time involvement when calculating concurrency and determining the correct modifiers for any concurrent cases.

3. Keep Your Medical Direction Compliant

You need to be familiar with the seven steps of medical direction and the exceptions that Medicare allows. Also remember, however, that the anesthesiologist can perform certain services (such as receive patients entering the operating suite for the next surgery) without interrupting medical direction.

Local watch: The medical direction “exceptions” vary by state, which can make coding tricky. Several state Medicare Administrative Contractors (MACs) publish Frequently Asked Questions which explain and might allow additional services, such as placing an arterial line while medically directing. Know those services your MAC allows — and make absolutely sure that your physician hasn’t met the requirements before you start to alter your claims.