MIPPA Revises Medicare Anesthesia Teaching Programs

Go to the source and find out how the new rules pertain to you.

By Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC

On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) adopted revised standards regarding Medicare anesthesia teaching programs. These changes result from the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), as announced in the 2010 Medicare Physician Fee Schedule (MPFS) final rule, subsequently implemented by CMS Transmittal 1859, Change Request (CR) 6706, and clarified by MLN Matters MM6706 Revised.

Anesthesia and Pain Management CANPC

As outlined in MM6706 Revised, these new standards:

  • Establish a special payment rule for teaching anesthesiologists;
  • Specify the periods during which the teaching anesthesiologist must be present during the procedure to qualify for payment based on the regular anesthesia fee schedule amount; and
  • Provide the Secretary of Health and Human Services (HHS) with a directive addressing payments for the anesthesia services of teaching certified registered nurse anesthetists (CRNA).

Teaching Anesthesiologists May Oversee Up to Two Cases

In previous years, when a teaching anesthesiologist was involved in a single case with an anesthesia resident, payment was the same as if the anesthesiologist performed the anesthesia case alone. If the anesthesiologist medically directed the provision of anesthesia services in two, three, or four concurrent cases, and any of the concurrent cases involved residents, the physician’s involvement in the resident case(s) was paid under the medical direction payment policy. Under medical direction, payment for the anesthesiologist service was based on 50 percent of the anesthesia fee schedule that applied if the anesthesiologist performed the case alone.

The new rules specify that a teaching anesthesiologist may receive payment under the MPFS, at the regular fee schedule level, if he or she is involved in the training of residents in:

  • A single anesthesia case;
  • Two concurrent cases; or
  • In a single case that is concurrent to another case paid under the medical direction rules.

The last of these provisions applies specifically when the concurrent case involves a CRNA, an anesthesia assistant (AA), or a student nurse anesthetist.

In other words, according to the Medicare Claims Processing Manual, chapter 12, section 50.C, “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 to two concurrent anesthesia cases involving residents.”

For the teaching anesthesiologist payment exception to apply, two conditions must be met.

1) The teaching anesthesiologist (or other anesthesiologists in the same physician group) must be present during all critical or key portions of the anesthesia service.

If different teaching anesthesiologists in the anesthesia group are present during the key or critical periods, the performing physician, for purposes of claims reporting, is the teaching anesthesiologist who started the case. The National Provider Identifier (NPI) of the teaching anesthesiologist who started the case must be indicated in field No. 24 of the CMS claim form. The NPI of the group would be indicated in field No. 33.

2) The teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) must be immediately available to furnish anesthesia services during the entire procedure.

Documentation should substantiate that the previously stated conditions have been met. The teaching anesthesiologist should use modifier AA Anesthesia services performed personally by anesthesiologist and certification modifier GC The Teaching Physician was present during the key portion of the service and was immediately available during other parts of the service when reporting his or her services (note that Medicare Part B does not pay residents for anesthesia services).

For example, if an anesthesiologist was involved in two concurrent cases (a total knee replacement, 01402 Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty, and a laparoscopic cholecystectomy, 00790 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) which both involved resident teaching, and documented requirements of the new rule were met, you would code the services: knee replacement, 01402-AA-GC; and laparoscopic cholecystectomy, 00790-AA-GC.

New Rules Also Refine CRNA Payment

As revised by CR 6706, Claims Processing Manual, chapter 12, section 140.5, “Payment for Anesthesia Services Furnished by a Teaching CRNA,” provides additional language to address payment for teaching CRNAs.

As in past years, a teaching CRNA (not under the medical direction of a physician) was paid under Medicare Part B, at the regular fee schedule rate, when he or she was present continuously and supervising a single case involving a student nurse anesthetist. In such a case, the CRNA would report the service using modifier QZ CRNA service: without medical direction by a physician. No payment could be made under Part B for the service provided by a student nurse anesthetist.

Under the new rules, however, a teaching CRNA can be paid at the regular fee schedule rate for each case when involved with two concurrent cases. Once again, the CRNA should append modifier QZ to each claim to indicate he or she is not medically directed by an anesthesiologist.

Medicare specifies that to bill the anesthesia base units, the CRNA involved with two concurrent cases must be present with the student nurse anesthetist during the pre- and post-anesthesia care for each of the two cases (ibid).

To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. MM6706 Revised allows, however, for the teaching CRNA to “decide how to allocate time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient’s health status and other factors.”

The teaching CRNA must document his or her involvement in the cases with the student nurse anesthetists. MM6706 Revised reminds specifically “that the teaching CRNA’s medical record documentation in these cases must be sufficient to support the payment of the fee and be available for review upon request.”

Go to the source: You can find more information about payment for teaching anesthesiologists and CRNAs in CR 6706, available at www.cms.hhs.gov/Transmittals/downloads/R1859CP.pdf. This change request includes updated portions of the Claims Processing Manual, chapter 12, sections 50 and 100.1.4, as well as new section 140.5. MM6706 Revised also may be found on the CMS website at: www.cms.hhs.gov/MLNMattersArticles/downloads/MM6706.pdf.


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