Medicare Compliance & Reimbursement

Question: Four certified registered nurse anesthetists (CRNAs) from our group were working on separate cases under the anesthesiologist's medical direction. An emergency patient comes in, and the anesthesiologist takes the case. He is no longer available to medically direct the CRNAs. How do I code the CRNA cases?

Answer: CMS states that a medically directing anesthesiologist can perform certain other services concurrently and retain his or her medical direction status. One example is "Addressing an emergency of short duration in the immediate area."

The answer for your situation depends on whether the anesthesiologist's involvement in the emergency case was of  "short duration" and whether he remained in the immediate area. If so, the anesthesiologist is still medically directing the CRNA cases and should submit his participation in the cases with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). Report each CRNA's case with modifier QX (CRNA service: with medical direction by a physician).

If the emergency case took more of the anesthesiologist's time and he is not available to the medically directed CRNAs, he can no longer be considered as medically directing the CRNAs. He cannot bill for his involvement in those cases. Submit the claims for the CRNAs with modifier QZ (CRNA service: without medical direction by a physician).