Wiki Billing Medical Supervision for CRNAs - NOT Medical Direction


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We're having quite the discussion in our office over proper use of anesthesia modifiers for billing CRNAs practicing without medical direction but with medical supervision. We are in a state that did not opt out of the medical supervision requirement for CRNAs.

There are two lines of thought.

1) Bill on line one, the anesthesiologist with the AD modifier and the 3 time units (4 if appropriate involvement is documented). On line two bill the CRNA with the QZ modifier.

2) Bill on line one, the same as above for the anesthesiologist. On line two bill the CRNA with the QX modifier.

Neither option is clearly correct. QZ says the CRNA did the work entirely independent of physician involvement. QX says they were medically directed when in fact they are medically supervised.

Any input or experience with this issue will be much appreciated!

Angela Beard
There is not a lot of information out there for the AD modifier but below are two links of articles that I was aware of.

Modifier AD Update

Date February 2012

State Indiana

Description of Update/Status

Claims for anesthesia services using modifier AD - Medically supervised by a physician, more than four concurrent anesthesia procedures - allows for three base units without a time factor unless the physician documents they were "present on induction."


The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 50 indicates that where a physician has medically supervised more than four concurrent procedures, the allowed amount is based on three base units and one time unit if the physician documents they were "present on induction."


Beginning April 1, 2013 WPS Medicare will provide reimbursement for three base units plus one time unit when the physician is present on induction. If the physician does not document he/she was present on induction, WPS Medicare will reimburse based on three base units without time. Providers should continue to convert hours into minutes and submit the total minutes in Box 24G of the CMS 1500 form or the Loop 2400 Segment 2-3700-SV104 in the 5010 electronic format. Medicare~Articles~Modifier Lookup~8EELAB1511

HCPCS Modifier AD

Medical supervision by a physician: more than four concurrent anesthesia procedures

Guidelines/Instructions: •This modifier may only be submitted with anesthesia procedure codes (e.g., CPT codes 00100 through 01999). Payment for services that are 'medically supervised' is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction.
•The units field must always be '1' when this modifier is submitted
Physician services may be reimbursed at the medically supervised rate in the following situations: •The anesthesiologist is involved in furnishing more than four procedures concurrently
•The anesthesiologist is performing other services while directing the concurrent procedures. There are several exceptions to this requirement: ◦Addressing an emergency of short duration in the immediate area
◦Administering an epidural or caudal anesthetic to ease labor pain
◦Periodic (rather than continuous) monitoring of an obstetrical patient
◦Receiving patients entering the operating suite for the next surgery
◦Checking or discharging patients in the recovery room
◦Handling scheduling matters

•These exceptions do not apply if the physician: ◦Leaves the operating suite for other than short durations
◦Devotes extensive time to an emergency case
◦Is otherwise not available to respond to the immediate needs of surgical patient

•CMS Pub. 100-04, Chapter 12 external link (PDF, 1 MB) ◦Definitions of personally performed, medically directed and medically supervised: Section 50
◦Definition of concurrent procedures: Section 50J
◦Anesthesia modifiers: Section 50K
◦Base units for anesthesia services: following Section 50K: Exhibit 1
That's all we could find, too. It still doesn't answer the question of how to best bill for the CRNA. If anyone can help, I'm still looking for that information.
We bill with QX due to the fact that our contract with our hospital doesn't allow the CRNA's to practice solely without an Anesthesiologist. Using the QZ modifier would get you full reimbursement as if the Anesthesiologist was personally performing (AA). AD will give you the reduction needed due to the Anesthesiologist Supervising and not Medically Directing and the CRNA portion should still be paid at 50% of the charge (QX). Hope this helps.

Coding and Compliance Manager

In which state do you practice?

We found something on the AMA website that said if every step of medical direction is not met, bill QZ. What's your take on that? My anesthesiologist tells me his practice is fairly unique in that he truly does practice medical supervision not direction. He is truly not involved in every case. More complicated cases, like open hearts, he is involved at the surgeon's request. In that case, he fulfills all seven (7) steps of medical direction.

I think, that being the case, we are billing correctly using QZ when the CRNA does the case with little to no input from the anesthesiologist.

Thanks in advance for your feed back!