Anesthesia Coding Alert

Clarify 'present and immediately available' up front to help your medical-direction claims

The size of your hospital's surgery department or the location of labor and delivery won't change your codes for procedures, but they can change the anesthesiologist's performance modifier--and his reimbursement.

You consider these types of factors when you-re deciding whether to report medical direction or medical supervision for the anesthesiologist's service, says Eileen Lorenco, RHIT, CS, CPC, coding manger with Lahey Clinic in Burlington, Mass. Anesthesiologists routinely step out from medically directed cases to perform other allowable services (such as starting a patient's labor epidural), so you need to be sure he's still -physically present and immediately available- under medical-direction guidelines before you code it as such. Know How the Factors Affect Coding If the anesthesiologist personally performs a case, you know where he is for the entire procedure and report modifier AA (Anesthesia services performed personally by anesthesiologist) with the procedure code (for Medicare cases or commercial carriers that follow Medicare rules). The carrier pays him for the entire case.

Break it down: Coding gets trickier when the anesthesiologist oversees other members of the team rather than personally performs cases. If he medically directs one CRNA, report modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) with the procedure code; if he directs from two to four anesthetists, report modifier QK instead (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals). Physicians who medically direct cases split the procedure fee with the other anesthetist(s) involved.

Remember: Cases don't qualify for medical-direction reporting simply because the anesthesiologist oversees a certain number of procedures. He must also meet all seven of CMS- medical-direction criteria, listed in the box later in this issue.

If the anesthesiologist does not meet all seven criteria for medical direction (or if the case load goes over four concurrent cases), you must report all of the cases as medically supervised (by appending modifier AD, Medical supervision by a physician: more than four concurrent anesthesia procedures) instead of medically directed. This shift in codes means changes to the physician's bottom line because he can only bill for three base units (and no time units) for medically supervised cases. That's a big difference from payment for personally performed or medically directed cases.

Note: If the anesthesiologist does not meet medical-direction criteria, the CRNA might be able to report the case as nonmedically directed (with QZ, CRNA service: without medical direction by a physician). Know the hospital's policies before coding this way because many only credential CRNAs to work in conjunction with anesthesiologists. Consider Individual Circumstances -I think Medicare made the term -immediately available- in the guidelines purposely vague to take into consideration that [...]