Payment Conditions for Anesthesiology Services
Medical Direction
For a single anesthesia case involving both a physician medical direction service and the service of the medically directed CRNA, the payment amount for each service may be no greater than 50 percent of the allowance. The total payment for both may not exceed the amount that would be paid had the service been furnished solely by the anesthesiologist.
Medical direction is a covered service only if the physician:
Performs a pre-anesthesia examination and evaluation.
Prescribes the anesthesia plan.
Personally participates in the most demanding procedures of the anesthesia plan, including induction and emergence.
Ensures that any procedures in the anesthesia plan that he does not perform are performed by a qualified anesthetist.
Monitors the course of anesthesia administration at frequent intervals.
Remains physically present and available for immediate diagnosis and treatment of emergencies.
Provides indicated post-anesthesia care.
Note: For medical direction, the physician must document in the medical record that he performed the pre-anesthetic exam and evaluation, provided indicated post-anesthesia care, was present during some portion of the anesthesia monitoring, and was present during the most demanding procedures, including induction and emergence, where indicated.
The requirement that the physician participate in the most demanding procedures of the anesthesia plan, including induction and emergence, were included at a time when general anesthesia was the usual mode of practice for anesthesia services. However, since that time, other types of anesthesia care, such as regional anesthetics and MAC have become more common.
For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or two concurrent anesthesia cases involving residents.
Two separate claims must be filed for medically directed anesthesia procedures—one for the anesthesiologist and one for the CRNA. Medical direction can occur in several different scenarios. When billing for the anesthesia services, please refer to the following examples for appropriate modifier usage:
An anesthesiologist is medically directing one CRNA. The anesthesiologist should bill with the QY modifier and the CRNA should bill with the QX modifier. The Medicare payment would be split equally between the two providers with each provider receiving 50 percent of the Medicare allowable amount for the procedure.
An anesthesiologist is medically directing two, three or four CRNAs. The anesthesiologist should bill with the QK modifier and the CRNA should bill with the QX modifier. The Medicare payment would be split equally between the two providers with each provider receiving 50 percent of the Medicare allowable amount for the procedure.
If the medical direction requirements are not met, a CRNA may submit a claim with the QZ modifier indicating the service was without medical direction by a physician.
Medical Direction Guidelines
• Only anesthesiologists will be reimbursed for medical direction.
• The anesthesiologist must be physically present in the operating suite to bill for direction of concurrent anesthesia procedures.
• Medical direction is defined as:
** Performing a pre-anesthetic examination and evaluation;
** Prescribing the anesthesia plan;
** Personally participating in the most demanding procedures in the anesthesia plan, including induction and emergence:
** Ensuring that any procedures in the anesthesia plan that he/she does not perform are rendered by a qualified individual;
** Monitoring the course of anesthesia administration at frequent intervals;
** Remaining physically present and available for immediate diagnosis and treatment of emergencies; and
** Providing the indicated post-anesthesia care.
• The anesthesiologist may bill for the direction of up to four concurrent anesthesia procedures for straight Medicaid recipients.
• Reimbursement will not be made for the direction of five or more anesthesia procedures being performed concurrently unless the patient is a Medicare/Medicaid beneficiary.
