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Anesthesia Coding Alert

You Be the Coder:

Seven Rules of Medical Direction

Published on Tue Aug 01, 2000

Question: In our anesthesiology practice, we medically direct certified registered nurse anesthetists (CRNAs) for anesthesia services. While we meet the seven rules of medical direction as mandated by the Health Care Financing Administration (HCFA), the anesthesia record does not always document that all seven steps were performed. In this instance, would it be appropriate to use the -QX modifier (CRNA service; with medical direction by a physician) or the -QZ modifier (CRNA service; without medical direction by a physician), since the documentation does not completely prove medical direction?

Tennessee Subscriber


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Answer: If you cannot meet through documentation that all seven steps were performed, then you should step down your coding (i.e., change modifiers). This would be similar to a surgeon using modifier -52 (reduced services).

Documentation by anesthesiologists is one of the most complex issues of providing care. When an anesthesiologist is medically directing, he or she must document the necessary items. However, getting the anesthesiologists or other physicians trained to do this is not always easy. One way to complete records is to do post-surgery coding (i.e., have late entries on the anesthesia record that make it more complete). This is not an ideal situation and should not be done as routine procedure. If you choose to do late entries, be sure that a copy of changes are included in the medical record for carrier audits at later dates.

Many conferences or symposiums on coding will instruct that carbon copies of the anesthesia record should never be separated from the original record until the patient is released from Post-Anesthesia/Recovery. At that point, the attending physician or anesthesiologist should review the record for completeness before routing copies to billing, medical records or other departments.

It would serve a great purpose if you and the anesthesiologist could review the anesthesia record and consider updating the form to allow for current guidelines. There are many forms already available, or you can call anesthesia departments in your area to ask for samples. Having check-off boxes and places for the attending physician to sign-off when he or she is in or out of the room may help you document medical direction more clearly.

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