Anesthesia Coding Alert

Aetna Healthcare broke new ground this summer with its decision to use several modifiers formerly used only for Medicare claims - and that decision will certainly impact anesthesia providers. First, the policy states that one of Medicare's MAC modifiers must be included with MAC claims (-QS, Monitored anesthesia care service; -G8, Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure; or -G9, Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition). This parallels Medicare's requirement for -QS on all MAC claims, although Albany, N.Y., anesthesiologist Scott Groudine, MD, says that guidelines for using -G8 and -G9 on Medicare claims vary by state. The Aetna policy also mentions guidelines for several CRNA and medical direction/supervision modifiers (-QX, CRNA service: with medical direction by a physician; -QZ, CRNA service: without medical direction by a physician; -AD, Medical supervision by a physician: more than four concurrent anesthesia procedures; and -QK, Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals).

It is important to note that modifier -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) is not included in the Aetna policy. This may be partly because the policy is based on Medicare's guidelines, and Medicare just recently began accepting -QY.

Many anesthesia providers aren't surprised by Aetna's move. "They were bound to realize that they were paying us more than Medicare does for the same services," says one ACA reader in Wisconsin. "Sooner or later they were going to lower their payments to us as well."

Groudine advises that practitioners keep the situation in perspective. "Unlike Medicare, Aetna isn't backed by the U.S. government. If you can't negotiate what you feel is a favorable contract with a carrier, you don't have to participate. If enough providers stop participating, the carrier will need to make changes in order to provide their policy holders with the promised anesthesia services."