CRNA anethesia billing modifiers

Anesthesia Billing for CRNAs

When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors.  First, the method of reporting claims.  As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services.  Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed” rule to come into play.  In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service”.   
      The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNAs.  According to the January, 2005 Ohio Job and Family Service Physician Handbook, “Services of a hospital employed CRNA/AA are included in the facility.”   In some cases, Medicare offers small hospitals that employ only one CRNA a “pass through” billing option.  When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital. 
      It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.  Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.  Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.  Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction.  No time is allowed for any of the concurrent cases.    You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.       The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.  Obtain state guidelines for each major carrier – Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember – the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.   
QZ:    (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.   
QX:   (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction. 
QK:   (physician modifier { used in conjunction with QX modifier} –  pays 50%) Medical direction of two, three or four concurrent procedures
QY:   (physician modifier { used in conjunction with QX modifier} –  pays 50%) MD is medically directing one CRNA  
AD:   (physician modifier { used in conjunction with QX modifier} –  pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures
Q6:  (physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source:  HCPCS, 2005.

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