Part B Insider (Multispecialty) Coding Alert

Medical Supervision Guidelines Could Decimate Your Reimbursement

When it comes to the patients your anesthesiologist monitors, three may be a crowd - but five or more spells much lower reimbursement.
 
If your anesthesiologist works in a busy practice, it may be easy for him to wind up having a number of patients under anesthesia at once. But if he is dealing with more than four patients at a time, Medicare considers his services to be medical supervision instead of medical direction.
 
The reimbursement for medical supervision is much lower than for medical direction, experts say. For medical supervision, the doctor only receives three base units plus one extra unit if he was present at induction, says Lee Broadston, president of BCS Inc. in Waconia, Minn. So if the anesthesiologist sees five patients, that adds up to 20 units in total.
 
With medical direction, though, the anesthesiologist can easily receive as many as 20 units per patient - or 80 units for four patients at once, Broadston says. Medicare reimburses medical direction based on the amount of time the physician performs the service. In most states, this means time units plus base units, times 50 percent of the conversion factor.
 
Use the -QK modifier to claim medical direction and the -AD modifier to claim medical supervision. Most computer systems will calculate reimbursement and watch for times when a physician strays into medical supervision, says Barbara Johnson with Loma Linda University Anesthesiology Medical Group in Loma Linda, Calif. But it still pays to review the charts yourself to make sure your physician didn't accidentally pass four patients at any point.
 
If the number of patients an anesthesiologist sees exceeds four even for a moment, then all the patients the anesthesiologist is seeing become medical-supervision cases automatically, Johnson says. And all of those cases stay medical supervision until they finish. "Physicians try very, very hard not to try to get themselves into that situation," she says. And if one case ends at 10:30 a.m., and another case begins at 10:30 a.m., those two cases are considered to take place at the same time for purposes of medical direction or supervision.