Wiki Anesthesia by CRNA

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Hello,
We have CRNAs that provide the anesthesia for our pain Doctors at the surgery center. They all work under the same TIN - same medical company, but different NPI numbers. We do have all the correct numbers in the correct box on the claim.

We are having issues with insurance companies denying the claim due to this. Do you think you can you add modifier 59 to the anesthesia claim help with this being processed and paid or should we use modifier XP? If you can, would you put 59-QZ-QS , -QZ-QS-59 / XP-QZ-QS , -QZ-QS-XP? Would you hold the anesthesia claim for a day or two to make sure the professional claim is received first?

Any other tips you may have on this?

Thank you!
 
It really depends on why the insurance companies are denying this. The modifier 59/XP is intended for unbundling services that would not normally be billed together, but anesthesia usually only bundles to a surgery if billed by the surgeon - this should not be a problem if your claims correctly identify that the anesthesia is being done by the CRNA who is a different provider and different specialty from the surgeon. If this is the reason the payers are denying, then that's really a mistake on their part and I would recommend working with them first to see what the root of the problem is and only use the modifier if it's necessary to get around it. But if it's another denial reason, then the modifier may not likely help correct the problem for you. Either way, I think the best starting point is to speak with the insurance plans and get an understanding of what is causing their denials and see if this can be corrected. In my experience it's never a good process to change your coding of claims based on an anticipation of a denial unless you have something in writing from payers to back up what you're doing.
 
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Thank you. I agree not to change the way we code just based on a denial. Some of the procedures bundle the anesthesia in the surgery code - such as a epidural injection. With that, I think the biller should work with insurance company as to the medical necessity on why anesthesia was needed with that procedure to secure reimbursement. But it is the denial due to the same TIN that are issues. Yes, I feel the biller should work with the insurance company on the claim being processed correctly, but this practice wants the modifier used in order to reduce that step in hopes that the claim will be processed the first time.

I guess what I really looking for is support that says "59" is not correct, modifier "XP" could be used but the biller should be working with insurance companies for payment.

The Modifier Explanation for 59 says "Modifier 59 applies to procedures or services not typically reported together but are appropriate in specific situations. Modifier 59 tells the payer that the provider does not ordinarily perform the procedure with another procedure for the same patient, on the same day, BY THE SAME PROVIDER. The procedures would normally be bundled under one code."

So, if it is a CRNA that provides the anesthesia and not the Doctor, this modifier would not be supported since it is not THE SAME PROVIDER...right?

Where as Modifier Explanation for XP "A provider appends this modifier to identify a distinct service that a patient receives from a different provider who performs the service on the patient."
 
What procedure codes are you using? This could be a medical necessity denial for the diagnosis needed in the Medical Policy. Especially if your denials are Medicare or Medicare HMO products.
 
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