Anesthesia Coding Alert

Look for documentation of the seven steps before reporting medical direction.

When reporting anesthesia services, one of the primary factors to consider is which of your providers oversaw the case, so you can assign the correct billing modifier. Anesthesia claims modifiers correspond to the four categories the Centers for Medicare & Medicaid Services (CMS) designed its anesthesia payment system around: personally performed, teaching, medical direction, and medical supervision.

Many of these terms are confused and used interchangeably, so we put together this primer to set the record straight. Keep reading for a quick refresher on what these classifications are and how you should report each service.

Pick Out Personally Performed Services

Cases that can be categorized as personally performed are the easiest to recognize and the simplest to report. This means the anesthesiologist administered the anesthesia and was solely responsible for the patient from the time of induction through emergence and hand-off to the post-anesthesia care team.

Do this: Submit the full claim under the anesthesiologist’s name and append modifier AA (Anesthesia services performed personally by anesthesiologist). Medicare payment is 100 percent of the allowed amount.

Key: The physician must personally perform the entire anesthesia service alone or be continuously involved in a single case with a student nurse anesthetist (SNA).

Keep Count of Concurrent Procedures

Things can get a bit trickier when the anesthesiologist oversees the work of another anesthesia provider. Start by identifying the number of concurrent cases in which the anesthesiologist was involved at that particular time. Remember that concurrent anesthesia procedures are those that overlap, even by one minute, and include all cases — not just Medicare.

Bear in mind: Payers may allow only three base units per procedure when the anesthesiologist is involved in more than four cases concurrently or performs other services while directing the concurrent procedures. The payer might recognize an additional time unit if the physician can document that they were present at induction, which only applies to general anesthesia cases.

Verify: “Make sure to look at your payer’s guidelines for specific instructions. Checking your local Medicare carrier is especially important as they may publish guidelines that will dictate how your practice will be reporting medical direction versus medical supervision,” advises Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Know When a Case Is Considered Teaching

Teaching occurs when a physician is involved in the training of physician residents in up to two concurrent cases. The training anesthesiologist must report the appropriate payment modifier along with modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) when billing these cases. The Medicare payment for a teaching case is 100 percent of the allowed amount.

Tip: “The GC modifier applies to all services, such as arterial line placement, and not just anesthesia services,” Dennis notes.

Understand Medical Direction Criteria

An anesthesiologist is allowed to be involved in more than one concurrent case if the physician is not personally performing the anesthesia. Medical direction earns higher reimbursement than medical supervision, but it also involves meeting stricter requirements before it can be reported.

Medical direction occurs when an anesthesiologist directs the concurrent delivery of anesthesia care by up to four qualified nonphysician anesthesia providers. CMS outlines seven criteria that must be met before you can report a case as medical direction instead of medical supervision — sometimes referred to as the seven steps of medical direction.

To qualify as medical direction, the anesthesiologist must:

1. Perform a pre-anesthesia examination and evaluation.
2. Prescribe an anesthesia plan.
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence.
4. Ensure that a qualified anesthetist performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform.
5. Monitor the course of anesthesia administration at intervals.
6. Remain physically present for all critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies.
7. Provide post-anesthesia care as indicated.

Your modifier choices to designate when an anesthesiologist medically directed a case are:

• QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)
• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)

Payment: If the work qualifies as medical direction, each case the anesthesiologist directs is reimbursed 100 percent — which will be split 50/50 between the physician and CRNA by Medicare and may vary by other payers.

Shift Coding Gears for Medical Supervision

The anesthesiologist’s involvement in cases shifts from medical direction to medical supervision when they do not meet all seven medical direction criteria in some geographical locations or are involved in more than four concurrent cases, Dennis explains. There are no requirements for the physician to provide hands-on care for medically supervised cases, but the anesthesiologist must be available to assist in any of the concurrent cases.

Overstepping the concurrency guideline is the most common reason for shifting from direction to supervision — adding a fifth concurrent case to the mix for as little as a minute is all it takes to change the designation.