Did you know that it’s not uncommon for anesthesia professionals to engage with patient
responsibilities? Anesthesia coding has a major impact on the procedures as well as revenue
payments. It happens especially when cases are complicated or when an anesthesiologist routinely
medically directs or medically supervises other healthcare providers.
This article provides you the useful scenarios to keep your own claims on the right payment track by
starting with correct documentation of providers.
Always Keep the Modifiers straight in Anesthesia coding:
Either you’re reporting care by an anesthesiologist, certified registered nurse anesthetist (CRNA),
or anesthesia assistant (AA). Every person’s involvement is typically reported separately with the
applicable modifier that also notes medical direction or supervision status.
Yet there are few insurance companies that do not require or accept medical direction modifiers as
recognized by the Center for Medicare & Medicaid Services (CMS). They are:
AA (Anesthesia services performed personally by anesthesiologist)
AD (Medical supervision by a physician: more than four concurrent anesthesia procedures)
QK (Medical direction of two, three, or four concurrent anesthesia procedures
involving qualified individuals)
QX (CRNA service: with medical direction by a physician)
QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an
anesthesiologist)
QZ (CRNA service: without medical direction by a physician).
How do they work in the real world?
Some special guidelines apply to the usage of modifiers, especially the ones related to medical
direction and medical supervision.
Consider the below examples from Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPMA, CPC, CPC-I, owner
of Perfect Office Solutions in Leesburg, Florida, to illustrate when you need to use modifiers to
clarify which healthcare providers played a role in this case.
Scenario 1: Anesthesiologist and CRNA work together: Healthcare providers offer kyphoplasty in the
office setting. The physician performs the lumbar kyphoplasty and the CRNA administers anesthesia.
How to code it: The anesthesiologist will report the correct procedure code(s) for the kyphoplasty
as:
22514 (Percutaneous vertebral augmentation, including cavity creation i.e. fracture reduction and
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body,
unilateral or bilateral cannulation (inclusive of all imaging guidance; lumbar) for the first level
+22515 (Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone
biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body,
unilateral or bilateral cannulation (inclusive of all imaging guidance; each additional thoracic or
lumbar vertebral body with the list done separately in addition to code for primary procedure) for
each additional level treated.
The CRNA will report the anesthesia with 01936 (Anesthesia for percutaneous image guided procedures
on the spine and spinal cord; therapeutic).
You will not report a medical direction/supervision modifier for the anesthesiologist because a
professional cannot personally perform a procedure while medically directing or supervising a CRNA.
You should, however, append modifier QZ to the CRNA’s claim.
Scenario-2: Unexpected cases added to the load: Three CRNAs from your group are working on separate
cases under the anesthesiologist’s or anesthesia professional’s medical direction. An emergency
patient comes in, and the anesthesiologist is called over.
How to code it? – The answer for the above situation relies on whether the anesthesiologist’s
involvement in the emergency case was of “short duration” and if he/she remained in the immediate
area.
CMS has stated that a medically directing anesthesiologist can perform certain services concurrently
and retain his or her medical direction status. One example is “Addressing an emergency of short
duration in the immediate area.”
If such a thing takes place, it means that the anesthesiologist is still medically directing the
CRNA cases and should report his/her participation in the cases with modifier QK. Don’t forget to
submit each CRNA’s claim with modifier QX.
In case of emergency that has involved more of anesthesiologist’s time, and if he/she is not
available to the medically directed CRNAs, then he/she can no longer be considered as medically
directing their services.
Most importantly, remember that an anesthesiologist can only medically direct up to four concurrent
cases. “If the anesthesiologist is medically directing four cases and takes another case, such as
the emergency patient in the above scenario, then it doesn’t matter whether the additional case is
of short duration,” says Dennis. “It becomes a fifth case, moving the anesthesiologist’s role to
medical supervision instead of medical direction, meaning you should append modifier AD to the
claim.”
Once when the anesthesiologist’s status shifts to medical supervision, they cannot bill for any of
their involvement in the cases they initially medically directed. Depending on the insurance and
documentation, one should submit the claims for the CRNAs with modifier QZ.
Scenario-3: Filing Claims with multiple Insurance companies: The anesthesiologist or anesthesia
professional medically directs three cases in which one payer is Medicare and the others are private
insurance companies.
How to code it? – When the time comes to calculate the concurrencies, all the insurance companies
cases go into the mix. It includes every case that determines whether to report the
anesthesiologist’s service as medical direction or medical supervision, even if you might not report
the concurrency modifiers to all the insurance companies.
Importance of Teaching Modifier in Anesthesia Coding:
When you code for anesthesiologists who help train residents in a teaching facility, there’s one
more provider modifier to keep on your track: GC – This service has been performed in part by a
resident under the direction of a teaching physician.
This modifier comes into play when a resident assists a physician in a teaching hospital or
healthcare organization.
When the anesthesiologist works as a “teaching physician” (TP) and supervises a resident’s services
in a clinic or hospital setting, one must report their physician’s work using the TP rules,
according to the Medicare Carriers Manual (MCM), section 15016.
Modifier GC does not only apply to E/M codes. This modifier moreover indicates that a resident
provided the procedure under a teaching physician’s direction.
Additionally, reporting modifier GC also indicates that the teaching physician was present for the
entire procedure or present for the key and/or critical portions of the procedure and immediately
available for the rest of the procedure – such as present in the operating suite.
There are various aspects you will have to check while performing anesthesia coding procedures. The
best way to have them coded to the finest level is to outsource these services to healthcare billing
and coding companies.
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