Anesthesia Coding Alert

Modifiers do not ensure reimbursement. 

One aspect of anesthesia coding that sets it apart from other specialties is the use of modifiers to help document the patient’s health status and who administered the anesthesia. Although they’re considered informational modifiers and won’t always affect your reimbursement, using them enhances your claims’ accuracy and better shows the care provided. Read on for your refresher on what each modifier represents and when you might use them.

Know the Professional Providers Involved 

Several professionals can be involved in helping deliver anesthesia care – an anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesia assistant (AA). Each person’s involvement is reported separately and with the applicable modifier that also notes medical direction/supervision status: 

• AA (Anesthesia services performed personally by anesthesiologist) 
  
• AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) 
  
• 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). 
  

Special guidelines apply to when and how you report some of these modifiers, particularly the ones related to medical direction and medical supervision (known as the 7 Rules of Medical Direction). Here are some examples of scenarios when you need to use the above modifiers.

Situation 1, Anesthesiologist and CRNA Work Together: Your providers offer kyphoplasty in the office setting. The physician performs the kyphoplasty and the CRNA administers anesthesia.

Coding: The anesthesiologist will report the correct procedure code(s) for the kyphoplasty (22523-+22525) and 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 physician cannot personally perform a procedure while medically directing or supervising a CRNA. You should, however, append modifier QZ (CRNA service: without medical direction by a physician) to the CRNA’s claim.

Situation 2, Unexpected Cases Added to the Mix:  Four CRNAs from your group are working on separate cases under the anesthesiologist’s medical direction. An emergency patient comes in, and the anesthesiologist takes the case. He is no longer available to medically direct the CRNAs.

Coding: CMS states that a medically directing anesthesiologist can perform certain other services concurrently and retain his or her medical direction status. One example is “Addressing an emergency of short duration in the immediate area.”

The answer for this situation depends on whether the anesthesiologist’s involvement in the emergency case was of “short duration” and whether he remained in the immediate area. If so, the anesthesiologist is still medically directing the CRNA cases and should submit his participation in the cases with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). Report each CRNA’s case with modifier QX (CRNA service: with medical direction by a physician).

If the emergency case took more of the anesthesiologist’s time and he is not available to the medically directed CRNAs, he can no longer be considered as medically directing the CRNAs. He cannot bill for any of his involvement in those cases. Submit the claims for the CRNAs with modifier QZ (CRNA service: without medical direction by a physician).

Situation 3, Filing Claims With Multiple Payers: The anesthesiologist medically directs three cases where one payer is Medicare and the others are private insurers.

Coding: When it’s time to calculate concurrencies, all payers’ cases go into the mix – not just Medicare. Include every case when determining whether to report the anesthesiologist’s service as medical direction or medical supervision, even if you might not report the concurrency modifiers to all payers.

Get Clear on the Patient’s Physical Status

Each anesthesia service reported also includes a physical status modifier that indicates the patient’s state when entering surgery and helps document the procedure’s complexity. The modifiers reflect the six rankings of patient physical status from the American Society of Anesthesiologists: 

• P1 (A normal healthy patient) 
  
• P2 (A patient with mild systemic disease) 
  
• P3 (A patient with severe systemic disease) 
  
• P4 (A patient with severe systemic disease that is a constant threat to life) 
  
• P5 (A moribund patient who is not expected to survive without the operation) 
  
• P6 (A declared brain-dead patient whose organs are being removed for donor purposes). 
  

The ASA (American Society of Anesthesiologists) does not provide concrete definitions for physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient.

Tip: Most of your anesthesiologist’s services will require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to support the claim.

Example: A patient with stable angina would be considered a P3 status. This patient has a systemic disease that could kill him, but he is stable and expected to do well. A patient with a P4 status has his life constantly threatened by his disease. The patient isn’t expected to die in the perioperative period, although it wouldn’t be totally unexpected if they do. Someone with unstable angina, or in congestive heart failure who needs surgery, would qualify for P4.

Note: Medicare and most other government carriers do not allow reporting or payment of P modifiers. Many private payers, however, will often reimburse for P modifiers if you follow their guidelines.