Anesthesia Billing for CRNAs
A timely topic if ever there was one! This issue continues to be a source of confusion to physician offices, billers, hospitals, and insurance companies, too. A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who is an anesthesia specialist and may administer anesthesia independently or under physician “medical direction” or “supervision.” CRNAs have been practicing in the United States since the civil war, and were the first nursing specialty to be accorded direct reimbursement rights under the Medicare program when President Ronald Reagan signed the Omnibus Budget Reconciliation Act of 1986 (OBRA), which included direct reimbursement for CRNAs under Medicare in Section 9320.
Reporting claims for a CRNA with carriers other than the Medicare program can be confusing, and there are several different issues for each practice to consider before determining the correct method. This article will address considerations such as employment status, state scope of practice laws, and carrier recognition – as well as the practical considerations of how to effectively file claims and calculate separate charges, when necessary.
One of the most important aspects to consider is who employs the CRNA. A 2003 survey conducted by the American Association of Nurse Anesthetists (AANA) shows approximately 37 percent of practicing CRNAs are employed by a physician group, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. In the majority of cases (53%), either the CRNA is employed by a group or is an independent contractor. CRNAs and those who employ them must accept assignment on their claims; however, filing rules for the various insurance carriers differ. According to the AANA, there are only 36 states that directly reimburse CRNAs under Medicaid; approximately 38 Blue Shield entities provide direct reimbursement to CRNAs, and approximately 22 states that mandate direct private insurance payment to CRNAs. That leaves a number of states out of the loop! So let’s try to clear this up…
CRNAs may be self-employed and bill for their own services. State scope of practice laws determine whether direction or supervision of a CRNA by a physician is required. In January, 2004, the American Society of Anesthesiologists (ASA) published a complete list of state requirements on their web site entitled, “The Scope of Practice of Nurse Anesthetists.” Although several states allow surgeons to supervise a nurse anesthetist – they are billed as “non-medically directed.” A surgeon may not wear two hats and collect payment as both the surgeon and the medically directing physician.