Risk and complication of anesthesia

Anesthesia - Risks and Complications

Although all types of anesthesia involve some risk, major side effects and complications from anesthesia are uncommon. Your specific risks depend on your health, the type of anesthesia used, and your response to anesthesia.

Personal risk factors

Your age may be a risk factor. In general, the risks associated with anesthesia and surgery increase in older people.

Certain medical conditions, such as heart, circulation, or nervous system problems, increase your risk of complications from anesthesia.

Some medicines can raise your risk of problems too. Make a list of all the prescription and over-the-counter medicines you take. And share your list with your doctors.

If you smoke, drink alcohol, or use illegal drugs, you may be more likely to have problems from anesthesia. It's important that you are honest when you talk with your surgeon and anesthesia specialist.

 

Anesthesia specialists, anesthesiologist and Anesthetist definition

Anesthesia specialists

Anesthesia specialists are responsible for making informed medical decisions to provide comfort and maintain vital life functions while you are receiving anesthesia and in recovery.

Anesthesia specialists include anesthesiologists and qualified nurse or dental anesthetists.

Anesthesiologist

Anesthesiologists are medical doctors who, after obtaining their medical degree and completing their internship, complete an additional 3 years of specialized training in an accredited anesthesiology residency program. They are certified by the American Board of Anesthesiology. As medical doctors, they have a wide range of knowledge about medications, medical care for diseases, how the human body works, and how it responds to the stress of surgery.

Anesthetist

Most anesthetists are nurses who have graduated from an accredited nurse anesthetist program and who have been certified by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). Nurse anesthetists are advanced practice nurses with specialized skills in anesthesia administration. A nurse anesthetist is usually supervised by an anesthesiologist or a surgeon, although law and practice may vary by state.

 

ANESTHESIOLOGIST DIRECTED ANESTHESIA

Medical direction may apply to a single anesthesia service furnished by a CRNA or up to four
concurrent anesthesia services. A physician who is directing the administration of anesthesia to four
surgical members is not expected to be involved routinely in furnishing any additional services to other
members. Addressing an emergency of short duration in the immediate area, administering an
epidural or caudal anesthetic to ease labor pain, or periodic rather than continual monitoring of an
obstetrical member would not substantially diminish the physician’s capacity to direct the CRNA
services.

The medical directing anesthesiologist must document in the member’s medical record that all
medical direction requirements have been met, including:

• Perform the pre-anesthetic examination and evaluation

• Prescribe the anesthesia plan


• Participate personally in the most demanding aspects of the anesthesia plan, including, if
applicable, induction and emergence

• Ensure a qualified individual performs any procedure in the anesthesia plan he/she does not
perform personally

• Monitor the course of anesthesia administration at frequent intervals

• Remain physically present and available for immediate diagnosis and treatment of emergency
that may develop

• Provide indicated post-anesthesia care.

A physician may appropriately receive members entering the operating suite for the next surgery while
directing concurrent anesthesia procedures. However, checking or discharging members in the
recovery room and handling scheduling matters are not compatible with reimbursement to the
physician for directing concurrent anesthesia procedures.

PCA - Patient Controlled Analgesia

Patient Controlled Analgesia

Patient controlled analgesia (PCA) services are reimbursable when they are
administered by an anesthesiologist and are performed for the control of postoperative
pain. A separately identifiable physician-recipient encounter should
be reflected in the medical record documentation. PCA pumps are usually
administered through an intravenous (IV) line or the PCA pump is connected
to an epidural catheter line.

Daily management of a PCA pump through an IV line is disallowed. When an
anesthesiologist provides the management of the PCA pump through an IV
line, the anesthesiologist will be allowed a total of four units and will be
considered a global payment for the management regardless of the number of
days the recipient remains on the pump. Use procedure code 90784 for daily
hospital management of intravenous patient-controlled analgesia.

The anesthesiologist should use the appropriate procedure code(s) when
filing claims for a single injection or for an injection including catheter
placement (epidural, subarachnoid, cervical, thoracic, lumbar, or sacral) when
the PCA pump is connected to an epidural line. Placement of the epidural
catheter and daily management of a subarachnoid or epidural catheter is not
reimbursable on the same date of service. Daily management of a
subarachnoid or epidural catheter is reimbursable on subsequent days.

Delivery of pain medication through intermittent injections, a regular infusion,
or by a PCA pump is included in the management of an epidural line whether
a registered nurse or a physician administers it. Additional units for a PCA
pump that is connected to an epidural line is not separately reimbursable.
The global surgical reimbursement fee to the surgeon includes the
management of a PCA pump for post-operative pain control and is not a
separately reimbursable item. Similarly, a physician’s global medical service
reimbursement includes the management of a PCA pump for recipients with
chronic pain control or terminal cancer and is not separately reimbursable.

Biling and coding tip for anesthesia CPT codes

CPT Anesthesia Code List

00100–00222 Head

00100 Anesthesia for procedures on salivary

glands, including biopsy

00102 Anesthesia for procedures on plastic

repair of cleft lip

Coding Tip

Do not use code 00102 for procedures performed on

the lip for conditions other than repair of cleft lip. For

other, non-cleft lip repairs, see code 00300.

For cleft palate repairs, see 00172.

00103 Anesthesia for reconstructive procedures

of eyelid (eg, blepharoplasty, ptosis

surgery)

00104 Anesthesia for electroconvulsive therapy

Coding Tip

Code 00104 may be denied when multiple electroconvulsive therapy (ECT) is provided. ECT (CPT code 90871) is a noncovered service by Medicare. Therefore, when anesthesia is performed for this reason, it will be denied as such.

00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

00124 otoscopy

00126 tympanotomy

Coding Tip

Codes 00120–00126 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00140 Anesthesia for procedures on eye; not otherwise specified

00142 lens surgery

00144 corneal transplant

Coding Tip

Codes 00140–00144 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00145 Anesthesia for procedures on eye; vitreoretinal surgery

Coding Tip

Code 00145 is for a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

This code is appropriate to use on any vitreoretinal procedures requiring the same anesthetic management.

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified

00162 radical surgery

00164 biopsy, soft tissue

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

Coding Tip:

Diagnosis coding is important to substantiate coverage of code 00170.

Anesthesia provided in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth is

noncovered by Medicare.

J codes J0120–J9999 Drugs Administered Including Oral and Chemotherapy Drugs

K codes K0001–K9999 Durable Medical Equipment Prosthetics, Orthotics, Supplies and Dressings (DMEPOS)

L codes L0100–L9999 Orthotic and Prosthetic Procedures, Devices

M codes M0064–M9999 Medical Services

P codes P2028–P9999 Pathology and Laboratory Services

Q codes Q0035–Q9999 Miscellaneous Services

(Temporary Codes)

R codes R0070–R9999 Radiology Services

T codes T1000–T9999 Medical Services

S codes S0009–S9999 Commercial Payers (Temporary

Codes)

V codes V2020–V9999 Vision, Hearing and Speech-

Language Pathology Services

CRNA anethesia billing modifiers

Anesthesia Billing for CRNAs

When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors.  First, the method of reporting claims.  As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services.  Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed” rule to come into play.  In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service”.   

      The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNAs.  According to the January, 2005 Ohio Job and Family Service Physician Handbook, “Services of a hospital employed CRNA/AA are included in the facility.”   In some cases, Medicare offers small hospitals that employ only one CRNA a “pass through” billing option.  When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital. 

      It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.  Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.  Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.  Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction.  No time is allowed for any of the concurrent cases.    You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.

      The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.  Obtain state guidelines for each major carrier - Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.

   
QZ:    (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.   
QX:   (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction. 
QK:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) Medical direction of two, three or four concurrent procedures
QY:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) MD is medically directing one CRNA  
AD:   (physician modifier { used in conjunction with QX modifier} -  pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures
Q6:  (physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source:  HCPCS, 2005.

Hospital and ASC anesthesia billing

A majority of hospitals and ambulatory surgery centers are missing an opportunity to collect earned revenue associated with their anesthesia services.


For example, a hospital performing 5,000 cases per year, could be missing nearly $1,500,000 per year.

The evolution of the Outpatient Perspective Payment System (OPPS) continues to drastically change the landscape of healthcare reimbursement, both eliminating and creating revenue streams.
One such revenue stream commonly disregarded by hospitals is anesthetic revenue.  Due to the low dollar value and high volume nature of anesthetic transactions, it historically was difficult to achieve a return on investment of accounts receivable resources.

As a result of over a billion dollars in anesthesia and anesthetic reimbursement experience, we have successfully engineered a system to capture this anesthetic revenue stream without any additional cost to your facility.  Our service is not intrusive on any of your current billing processes, does not require additional hospital resources, and as a standalone service eliminates any administrative oversight.


Common result(s) from our service:

    * Increased revenue from anesthesia expert resources concentrating on reimbursement for drugs utilized in anesthesia.
    * Eliminate subsidization of anesthesia departments.
    * Minimized expenditures on drugs by accessing group discount purchasing organizations.
    * Monitoring distributor and producer pricing schedules for optimal inventory cost management.


To help your finance team gain a better value for the revenue impact we are referring; simply download our one-page survey and my team will be happy to complete a complimentary anesthetic revenue forecast along with a recoverable estimate for your facility's historic cases. 

Time truly is money, especially due to the fact that with every day that passes, your facility foregos the ability of capturing historic revenue, due to timely filing constraints of the third-party payors. 

If you have any questions and/or concerns regarding the survey or any of our services, please do not hesitate to call us directly at 877-358-9819 or email me via our info@anestheticbilling.com email address. 

Typical Scenario:  An inpatient procedure is completed and the hospital will bill their facility fee, the surgeon will bill their professional fee and the anesthesiologist will bill their professional fee.

Missed Opportunity:  The hospital's billing service assumes that all of the anesthesia related items are already included in those fees and not aware that many items are able to be billed individually.  Since these items are typically smaller dollar amount items, they fall under the hospital's write off amount (typically set around $500); thus never collected.

The Dollar Amount:  Take the number of cases your facility performs per year and multiply it by your own write off policy amount (typically $500 per case).  A portion of that dollar amount could be added back into your bottom-line this year.

Anesthesia Billing for CRNAs

When filing claims through the Medicare program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are revenue neutral - meaning reimbursement is equal to the same amount.  For example, when medical direction modifiers “QK and QX” are reported (see table below), reimbursement is divided equally (50% and 50%) between the physician and the CRNA.  When a CRNA is non-medically directed, full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems.  Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!  

      Many private insurers expect CRNA services to be billed under the anesthesiologist, on one line of the claim form. Reporting separately may result in a claim denial or improper payment.  An additional confusion, since many practices generally equally split the full amount of the bill between the physician and CRNA, is that the claim is viewed as a duplicate.  Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.

      One way to avoid confusion when you must bill two claims, i.e. to collect a Medicare secondary balance, is to charge different amounts for the physician and CRNA.  For example, in our practice we assigned 70% of the conversion factor to the physician and 30% to the CRNA; however, your practice may choose to assign a different value.    Assigning different values when claims must be split helps identify and separate the services of the physician and the CRNA, as well as decrease odds the claims will be mistaken as duplicate.  It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!

How can you tell when to send separate claims?  One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNAs. To receive payment from carriers that require two claims, the CRNA must have a valid provider number and have reassigned their benefits.  It is important to ensure the provider number is valid before the CRNA begins working.  Many practices lose revenue by their inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA whose number is not yet in place, such as temporary providers.  Although short-term contract or temporary CRNAs are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.

      In most instances, CRNAs are prohibited from using the Q6 modifier to receive payment, since by definition the modifier indicates the service was provided by a “physician.” However, as to be expected in the anesthesia world of billing, there are no “absolutes”! Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6 modifier by CRNAs.  Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.

base units of Anesthesia cpt code - list 2

CPT CODES BASE UNITS
00930 4
00932 4
00934 6
00936 8
00938 4
00940 3
00942 4
00944 6
00948 4
00950 5
00952 4
01112 5
01120 6
01130 3
01140 15
01150 10
01160 4
01170 8
01173 12
01180 3
01190 4
01200 4
01202 4
01210 6
01212 10
01214 8
01215 10
01220 4
01230 6
01232 5
01234 8
01250 4
01260 3
01270 8
01272 4
01274 6
01320 4
01340 4
01360 5
01380 3
01382 3
01390 3
01392 4
01400 4
01402 7
01404 5
01420 3
01430 3
01432 6
01440 8
01442 8
01444 8
01462 3
01464 3
01470 3
01472 5
01474 5
01480 3
01482 4
01484 4
01486 7
01490 3
01500 8
01502 6
01520 3
01522 5
01610 5
01620 4
01622 4
01630 5
01634 9
01636 15
01638 10
01650 6
01652 10
01654 8
01656 10
01670 4
01680 3
01682 4
01710 3
01712 5
01714 5
01716 5
01730 3
01732 3
01740 4
01742 5
01744 5
01756 6
01758 5
01760 7
01770 6
01772 6
01780 3
01782 4
01810 3
01820 3
01829 3
01830 3
01832 6
01840 6
01842 6
01844 6
01850 3
01852 4
01860 3
01916 5
01920 7
01922 7
01924 6
01925 8
01926 10
01930 5
01931 7
01932 7
01933 8
01935 5
01936 5
01951 3
01952 5
+ 01953 1
01958 5
01960 5
01961 7
01962 8
01963 10
01965 4
01966 4
01969 5
01990 7
01991 3
01992 5

CPT code and base unit - List 1

CPT CODES BASE UNITS
00100 5
00102 6
00103 5
00104 4
00120 5
00124 4
00126 4
00140 5
00142 6
00144 6
00145 6
00147 6
00148 4
00160 5
00162 7
00164 4
00170 5
00172 6
00174 6
00176 7
00190 5
00192 7
00210 11
00211 10
00212 5
00214 9
00215 9
00216 15
00218 13
00220 10
00222 6
00300 5
00320 6
00322 3
00326 8
00350 10
00352 5
00400 3
00402 5
00404 5
00406 13
00410 4
00450 5
00452 6
00454 3
00470 6
00472 10
00474 13
00500 15
00520 6
00522 4
00524 4
00528 8
00529 11
00530 4
00532 4
00534 7
00537 10
00539 18
00540 12
00541 15
00542 15
00546 15
00548 17
00550 10
00560 15
00561 25
00562 20
00563 25
00567 18
00566 25
00580 20
00600 10
00604 13
00620 10
00622 13
00625 13
00626 15
00630 8
00632 7
00634 10
00635 4
00640 3
00670 13
00700 4
00702 4
00730 5
00740 5
00750 4
00752 6
00754 7
00756 7
00770 15
00790 7
00792 13
00794 8
00796 30
00797 11
00800 4
00802 5
00810 5
00820 5
00830 4
00832 6
00834 5
00836 6
00840 6
00842 4
00844 7
00846 8
00848 8
00851 6
00860 6
00862 7
00864 8
00865 7
00866 10
00868 10
00870 5
00872 7
00873 5
00880 15
00882 10
00902 5
00904 7
00906 4
00908 6
00910 3
00912 5
00914 5
00916 5
00918 5
00920 3
00921 3
00922 6
00924 4
00926 4
00928 6

Radiologic Anesthesia Coding

In keeping with standard anesthesia billing guidelines for Medicare, only one anesthesia code may be reported for anesthesia services provided in conjunction with radiological procedures. Radiological Supervision and Interpretation (S & I) codes will usually be applicable to radiological procedures
being performed.

The appropriate S & I code may be reported by the appropriate provider (radiologist, cardiologist, neurosurgeon, radiation oncologist, etc.). Accordingly, S & I codes are not included in anesthesia codes referable to these procedures; only the appropriate provider, however, may bill for S & I services. CPT code 01920 (Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan- Ganz catheter) can be reported for monitored anesthesia care (MAC) in patients who are critically ill or critically unstable.

If the physician performing the radiologic service places a catheter as part of that service, and, through the same site, a catheter is left and used for monitoring purposes, it is inappropriate for either the anesthesiologist/certified
registered nurse anesthetist or the physician performing the radiologic procedure to bill for placement of the monitoring catheter (e.g., CPT codes 36500, 36555-36556, 36568-36569, 36580, 36584, 36597).

Certified Registered Nurse Anesthetist billing

Anesthesia Billing for CRNAs

A timely topic if ever there was one!  This issue continues to be a source of confusion to physician offices, billers, hospitals, and insurance companies, too. A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who is an anesthesia specialist and may administer anesthesia independently or under physician “medical direction” or “supervision.” CRNAs have been practicing in the United States since the civil war, and were the first nursing specialty to be accorded direct reimbursement rights under the Medicare program when President Ronald Reagan signed the Omnibus Budget Reconciliation Act of 1986 (OBRA), which included direct reimbursement for CRNAs under Medicare in Section 9320. 

Reporting claims for a CRNA with carriers other than the Medicare program can be confusing, and there are several different issues for each practice to consider before determining the correct method. This article will address considerations such as employment status, state scope of practice laws, and carrier recognition – as well as the practical considerations of how to effectively file claims and calculate separate charges, when necessary.

      One of the most important aspects to consider is who employs the CRNA. A 2003 survey conducted by the American Association of Nurse Anesthetists (AANA) shows approximately 37 percent of practicing CRNAs are employed by a physician group, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. In the majority of cases (53%), either the CRNA is employed by a group or is an independent contractor.  CRNAs and those who employ them must accept assignment on their claims; however, filing rules for the various insurance carriers differ.  According to the AANA, there are only 36 states that directly reimburse CRNAs under Medicaid; approximately 38 Blue Shield entities provide direct reimbursement to CRNAs, and approximately 22 states that mandate direct private insurance payment to CRNAs.  That leaves a number of states out of the loop!  So let’s try to clear this up…

 CRNAs may be self-employed and bill for their own services.  State scope of practice laws determine whether direction or supervision of a CRNA by a physician is required.  In January, 2004, the American Society of Anesthesiologists (ASA) published a complete list of state requirements on their web site entitled, “The Scope of Practice of Nurse Anesthetists.”  Although several states allow surgeons to supervise a nurse anesthetist – they are billed as “non-medically directed.” A surgeon may not wear two hats and collect payment as both the surgeon and the medically directing physician. 

Anesthesia with Manipulation CPT codes

 CPT Codes:

21073     Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
22505     Manipulation of spine requiring anesthesia, any region
23700     Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
24300     Manipulation, elbow, under anesthesia
25259     Manipulation, wrist, under anesthesia
26340     Manipulation, finger joint, under anesthesia, each joint
27194     Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia
27275     Manipulation, hip joint, requiring general anesthesia
27570     Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
27860     Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

Proven Diagnosis Codes:

718.51     Ankylosis of joint of shoulder region
718.52     Ankylosis of upper arm joint
718.56     Ankylosis of lower leg joint
726.0     Adhesive capsulitis of shoulder
733.19     Pathologic fracture of other specified site
805.6     Closed fracture of sacrum and coccyx without mention of spinal cord injury
806.61     Closed fracture of sacrum and coccyx with complete cauda equina lesion
806.62     Closed fracture of sacrum and coccyx with other cauda equina injury
806.79     Open fracture of sacrum and coccyx with other spinal cord injury
808.0     Closed fracture of acetabulum
808.2     Closed fracture of pubis
808.41     Closed fracture of ilium
808.42     Closed fracture of ischium
808.43     Multiple closed pelvic fractures with disruption of pelvic circle
808.49     Closed fracture of other specified part of pelvis
812.4     Closed fracture of lower end of humerus (Incomplete code - additional digit required)
813.01     Closed fracture of olecranon process of ulna
839.41     Closed dislocation, coccyx
839.42     Closed dislocation, sacrum
839.69     Closed dislocation, other location
V43.65     Knee joint replacement by other means

Unproven Diagnosis Codes:

524.60     Unspecified temporomandibular joint disorders
524.69     Other specified temporomandibular joint disorders
718.25     Pathological dislocation of pelvic region and thigh joint
718.54     Ankylosis of hand joint
718.55     Ankylosis of pelvic region and thigh joint
718.57     Ankylosis of ankle and foot joint
808.43     Multiple closed pelvic fractures with disruption of pelvic circle

Anesthesia CPT code that require authorization

 Anesthesiologists are NOT required to request prior authorization. The surgeon must obtain prior authorization when required for procedures identified in the Medical and Surgical Procedure Code List included with the Utah Medicaid

Provider Manual for Physician Services.

The anesthesiologist is required to enter the prior authorization number obtained by the surgeon for the CPT code when billing an ASA code related to a CPT procedure for a hysterectomy, sterilization or abortion. The ASA

procedure codes listed below are associated with surgical codes that may require prior authorization by Medicaid.

If federal requirements for obtaining prior authorization for a hysterectomy, sterilization or abortion are not met,Medicaid cannot reimburse either the physician or the anesthesiologist. Exceptions (to the requirement that the surgeon obtain Prior Authorization before the procedure is performed) can

be considered ONLY under one of the following circumstances:

1. The procedure was performed in a life-threatening or justifiable emergency situation.

2. Medicaid is responsible for the delay in prior authorization.

3. The patient is retroactively eligible for Medicaid.

Retroactive authorization for services related to these exceptions may be granted "after-the-fact" with appropriate documentation and review. If approved, the associated ASA code may also be reimbursed.

For additional information about the prior authorization process, refer to the Utah Medicaid Provider Manual,

SECTION I, or contact Medicaid Information.

ASA Codes Associated with CPT Codes That May Require Prior Authorization

00402 Anesthesia for reconstructive breast procedures (reduction, augmentation, muscle flaps)

00580 Anesthesia for heart transplant or heart-lung transplant

00796 Liver transplant (recipient)

00840 Anesthesia for intraperitoneal procedures in lower abdomen (hysterectomy and sterilization)

00846 Anesthesia for radical hysterectomy

00848 Anesthesia for pelvic exenteration

00855 Anesthesia for cesarean hysterectomy

00922 Anesthesia for seminal vesicles

00926 Male, external genitalia; radical orchiectomy, inguinal

00928 Anesthesia for inguinal orchiectomy

00932 Anesthesia for complete amputation of penis

00934 Anesthesia for radical amputation of penis with bilateral inguinal lymphadenectomy

00936 Anesthesia for radical amputation of penis with bilateral inguinal and iliac lymphadenectomy

00940 Anesthesia for abortion procedures

00944 Anesthesia for vaginal hysterectomy

00952 Anesthesia for hysteroscopy

Concurrent Medically Directed Anesthesia Procedures

Concurrent Medically Directed Procedures

Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether the other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and one Medicare patient, this represents three (3) concurrent cases.

The following example illustrates this concept and guides physicians in determining how many procedures are directed:
Procedures A through E are medically directed procedures involving CRNAs. The starting and ending times for each procedure represent the periods during which anesthesia times are counted.

Procedure A begins at 8:00AM and ends at 8:20AM
Procedure B begins at 8:10AM and ends at 8:45AM
Procedure C begins at 8:30AM and ends at 9:15AM
Procedure D begins at 9:00AM and ends at 12:00 noon
Procedure E begins at 9:10AM and ends at 9:55AM

Procedure     Number of Concurrent Medically Directed Procedures     Base Unit Reduction Percentage

A                           2                                                                                              10%
B                           2                                                                                              10%
C                           3                                                                                              25%
D                           3                                                                                              25%
E                           3                                                                                               25%


A physician who is concurrently directing the administration of anesthesia to not more than four (4) surgical patients cannot ordinarily be involved in rendering additional services to other patients. However, addressing an emergency of short duration in the immediate area,administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.

However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. No fee schedule payment is made.

The examples listed above are not intended to be an exclusive list of allowed situations. It is expected that the medically-directing anesthesiologist is aware of the nature and type of services he or she is medically directing, and is personally responsible for determining whether his supervisory capacity would be diminished if he or she became involved in the performance of a procedure. It is the responsibility of this medically-directing anesthesiologist to provide services consistent with these regulations.

Payment rules

PAYMENT AND REIMBURSEMENT - Anesthesia

Payment at Medically Supervised RateOnly three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.


Payment Rules The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor.

The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Participating Conversion Factor = Allowance
• Non-Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ)
(Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

Anesthesia payment reimbursment tips

PAYMENT AND REIMBURSEMENT - Anesthesia


Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.


Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.

Anethesia billing modifier QK, QX AND G8,G9

Medicare Part B Anesthesia Modifiers

Medicare’s coverage of anesthesia services range from the least intensive to the most intensive services and include:
1. Local or topical anesthesia - the least intense;
2. Moderate (conscious sedation);
3. Regional anesthesia; and
4. General anesthesia – monitored anesthesia care (MAC).

Medicare covers MAC when provided for services considered reasonable and necessary. Services involving the administration of anesthesia are reported by the use of a 5-digit anesthesia procedure code (00100 – 01999) along with applicable modifiers.

A surgeon or physician cannot bill for anesthesia at the same time he/she is performing surgery. The Centers for Medicare and Medicaid Services (CMS) recently published Medicare Learning Network (MLN) article MM5618 “Anesthesia Services Furnished by the Same Physician Providing the Medical and Surgical Service – Revised.” This article can be found in Medicare B News Issue 240, October 2, 2007 and covers conscious sedation codes 99143, 99144, 99145, 99148, 99149 and 99150. Providers who bill these codes are encouraged to review this article thoroughly.

Medically directed anesthesia services should be billed using the appropriate modifiers listed below.
•AA: Anesthesia services personally performed by an anesthesiologist. 
This modifier allows full fee schedule reimbursement.

• AD: Medical supervision by a anesthesiologist: more than 4 concurrent anesthesia procedures 
Per the Internet Only Manual (IOM) Publication 100-04; Chapter 12, Section 50.D: “Carriers may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit may be recognized if the anesthesiologist can document that he or she was present at induction.”


• QK: Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals. 
This modifier limits payment to 50% of the amount that would have been allowed if personally performed by a anesthesiologist or non-supervised CRNA.

• QX: CRNA service with medical direction by a anesthesiologist.
This modifier limits payment to 50% of the amount that would have been allowed if personally performed by an anesthesiologist or non-supervised CRNA.

• QY: Anesthesiologist medically directs one CRNA. 
This modifier limits payment to anesthesiologist and CRNA to 50% of the amount that would have been allowed if personally performed by anesthesiologist.

• QZ: CRNA service without medical direction by a anesthesiologist.
This modifier has no affect on payment and the allowed amount is what would have been allowed if personally performed by an anesthesiologist.

As a reminder, the anesthesia modifiers above are pricing modifiers and must be listed in first position to insure correct reimbursement.

The modifiers below: QS, G8 and G9 modifiers are informational only and do not affect payment. Informational modifiers must be used in the second modifier position, in conjunction with a pricing anesthesia modifier in the first modifier position.

• QS: Monitored anesthesia care (MAC)

• G8: MAC for deep complex complicated or markedly invasive surgical procedures and may be used in lieu of modifier QS.

• G9: MAC for a patient who has a history of severe cardiopulmonary condition and may be used in lieu of modifier QS.

In Medicare B News Issue 246 June 24, 2008 NAS published “Anesthesia Base Rate Pricing.” This article is a good resource to help providers determine correct base and time units as well as the reimbursement formula.
Applies to the states of: AK, AZ, MT, ND, OR, SD, UT, WA & WY.

Billing for Anesthesia Services

Claims Documentation Requirements
 

Submit claims for anesthesia services on the CMS-1500 claim form or the electronic equivalent. Use specific CPT American Society of Anesthesiology (ASA) anesthesia codes or surgical codes with the appropriate anesthesia modifier. For authorized surgical services, MHCP prefers that anesthesia services are billed using surgical procedure codes with the appropriate anesthesia modifier.
 

Anesthesiologists and CRNAs must comply with MHCP requirements for billing sterilization procedures. Submit a Sterilization Consent Form, signed and dated by the recipient and the physician, with anesthesia claims for sterilization procedures.

Exact Minutes

Submit the exact number of minutes from the preparation of the patient for induction to the time when the anesthesiologist or the CRNA was no longer in personal attendance or continues to be required. Enter only the number of minutes in the units box. MHCP will calculate the base units
for each procedure.

Modifiers

To properly identify the exact nature of the service provided, use the following modifiers: 

Anesthesia Modifiers

AA - Anesthesia services performed personally by anesthesiologist
AD - Medical supervision by a physician: more than four concurrent anesthesia procedures
QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QS - Monitored anesthesia care services
QX - CRNA service with medical direction by an anesthesiologist
QY - Anesthesiologist medically directs one CRNA
QZ - CRNA service without medical direction by an anesthesiologist

Conscious Sedation and Deep Sedation

Conscious Sedation

The intent of conscious sedation is for the patient to remain conscious and able to communicate during the entire procedure. The patient retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and/or verbal command. Conscious sedation includes performance and documentation of pre- and post
sedation evaluations of the patient, administration of the sedation and/or analgesic agents, and monitoring of cardiorespiratory functions (pulse oximetry, cardio respiratory monitor, and blood pressure).

Conscious sedation may be administered by physicians (MDs) who have received training in moderate sedation. Follow 2006 CPT guidelines for the use of conscious sedation codes. Conscious sedation codes cannot be billed when anesthesia services are provided at the same time.
 

Deep Sedation
 

Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Deep sedation may be administered by emergency medicine physicians (MDs) whose advance
practice training has prepared them for airway management, advanced life support and rescue from any level of sedation.

Use the appropriate anesthesia or surgical procedure code to bill deep sedation and indicate the exact number of minutes in direct recipient contact. When deep sedation is performed by emergency medicine physicians, add modifier AA to the procedure code.

Monitored Anesthesia Care (MAC)

Monitored anesthesia care is a specific anesthesia service in which an anesthesiologist or CRNA has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.

Monitored anesthesia care includes all aspects of anesthesia care: a pre-procedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist or CRNA must be continuously physically present and provide a number of specific services, including but not limited to:

• Monitoring of vital signs, maintenance of the patient’s airway and continual evaluation of vital functions;

• Diagnosis and treatment of clinical problems that occur during the procedure;
 

• Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort;
 

• Provision of other medical services as needed to accomplish the safe completion of the procedure;
 

• Anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely. Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. If, for an extended period, the patient is rendered unconscious
and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic.

Anesthesia Medical direction guidelines.

Criteria for Medical Direction

Anesthesiologists can be reimbursed for the personal medical direction (as distinguished from supervision) that they furnish to CRNAs.

Medical direction services personally performed by an anesthesiologist will be reimbursed only if the anesthesiologist:
• Performs a pre-anesthetic examination and evaluation;
• Prescribes the anesthesia plan;
• Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence (if applicable);
• Ensures that any procedures in the anesthesia plan that he/she does not perform are performed by a qualified individual;
• Monitors the course of anesthesia administration at frequent intervals;
• Remains physically present in the surgical suite and available for immediate diagnosis and treatment of emergencies; and
• Provides indicated post-anesthesia care.
 

If anesthesiologists are in a group practice, one physician member may provide the preanesthesia examination and evaluation, and another may fulfill the other criteria. Similarly, one physician member of the group may provide post anesthesia care, while another member of the group provides the other component parts of anesthesia services. However, the medical record
must indicate that physicians provided the services and identify the physicians who rendered them.

MHCP will reimburse anesthesiologists for supervision of residents per Medicare’s formula and restrictions. The teaching physician must be present during induction, emergence, and during all critical portions of the procedure, and immediately available to provide services during the entire procedure. The documentation in the medical records must indicate the teaching anesthesiologist’s presence or participation in the administration of the anesthesia. The teaching physician’s presence is not required during the pre-operative or post-operative visits with the recipient. MHCP follows Medicare guidelines for reimbursement to anesthesiologists for the supervision of residents. MHCP does not reimburse for anesthesia assistants or interns.

Pre and post anesthetic service and eligible providers

Pre-anesthetic Evaluations and Post-operative Visits

MHCP uses the CMS list of base values, which were adopted from the relative base values established by the ASA. The base value for anesthesia services includes usual pre-operative and post-operative visits. No separate payment is allowed for the pre-anesthetic evaluation regardless of when it occurs unless the recipient is not induced with anesthesia because of a cancellation of
the surgery. 

If an anesthetic is not administered due to a cancellation of the surgery, the anesthesiologist or the independent CRNA may bill an E/M CPT code that demonstrates the level of service performed.

Eligible Providers

Anesthesiologists (MDA)

Certified Registered Nurse Anesthetist (CRNA). CRNAs must enroll and sign a provideragreement in order to be eligible for reimbursement.

Physicians (MDs) under limited conditions as described in the sections on conscious sedation and deep sedation.

Anesthesia provider types

Anesthesiology: The practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during and after surgery.
 

Anesthesiologist: A physician who specializes in anesthesiology and is board certified as an anesthesiologist.
 

Certified Registered Nurse Anesthetist (CRNA): An advance practice registered nurse. CRNAs are registered nurses with a baccalaureate degree who have completed an additional 24 to 36 months of training in anesthesiology in an accredited program and are certified by the Council on Certification of Nurse Anesthetists, or the Council on the Certification of Nurse Anesthetists of the American Association of Nurse Anesthetists (AANA).
 

Personally Performed: To be considered personally performed, the anesthesiologist may not be involved in any other procedure or duties that take him/her out of the operating room. It should be assumed that if the anesthesiologist leaves the operating room, he/she is performing other
duties. If the anesthesiologist leaves the operating room to perform any other duties, the anesthesia procedure may not be billed as personally performed.
 

Physician: A medical doctor (MD) who is licensed to provide health services within the scope of his/her profession.

What is base unit and Time unit

Base Units

Each anesthesia code (procedure codes 00100-01999) is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing fee schedule allowances.

Anesthesia services are paid on the basis of a relative value system, which include both base and actual time units. Base units take into account the complexity, risk, and skill required to perform the service.

For the most current list of base unit values for each anesthesia procedure code can be found on the Anesthesiologist Center page on the CMS website at:
http://www.cms.hhs.gov/center/anesth.asp

Time Units

Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.

Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

For anesthesia claims, the elapsed time, in minutes, must be reported. Convert hours to minutes and enter the total minutes required for the procedure in Item 24G of the CMS-1500 claim form or electronic media claim equivalent.
Time units for physician and CRNA services - both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. The table below illustrates the conversion from minutes to units used by the carrier for
processing:

Minutes    Units
1-2            0.1 

16-17         1.1
3               0.2

18             1.2
4-5            0.3 

19-20        1.3

6              0.4 

21            1.4
7-8           0.5 

22-23        1.5
9              0.6

24            1.6
10-11       0.7

25-26       1.7
12            0.8 

27           1.8
13-14       0.9 

28-29       1.9
15           1.0 

30           2.0

NOTE: Time Units are not recognized for CPT codes 01995 (Regional IV administration of local anesthetic agent or other medication (upper or lower extremity)) and 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration).

Payment for Multiple Anesthesia Procedures and Add-On Codes

Multiple Anesthesia Procedures

Payment may be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. Payment is based on the base unit of the anesthesia procedure with the highest base unit value and the total time units based on the multiple procedures with the exception of the new add-on codes. On the CMS-1500 claim form, report the anesthesia procedure code with the highest base unit value in Item 24D. In Item 24G, indicate the total time for all the procedures performed.

Add-On Codes

Add-on codes exist for anesthesia involving burn excisions or debridement and obstetrical anesthesia. The add-on code is billed in conjunction to the primary anesthesia code. In the burn area, code 01953 is used in conjunction with code 01952. In the obstetrical area, code 01968 or 01969 is used in conjunction with code 01967. All anesthesia time should be reported only with the primary anesthesia code involving burn excisions or debridement. Anesthesia time for the obstetrical codes should be reported separately on the primary code and the add-on code.

Anesthesia Billing and coding

Billing Instructions

Claims must be submitted on the claim Form CMS-1500 or electronic media claim equivalent.

The following are specific to anesthesia claims submission:

• Item 24D – the appropriate anesthesia modifier must be reported

• Item 24G – the actual anesthesia time, in minutes, must be reported.

Modifiers

Anesthesia modifiers must be used with anesthesia procedure codes to indicate whether the procedure was personally performed, medically directed, or medically supervised.

AA  - Anesthesia services personally performed by the anesthesiologist

AD  - Medical supervision by a physician; more than four concurrent anesthesia services

G8 -  Monitored anesthesia care (an informational modifier, does not affect reimbursement)

G9 -  MAC for at risk patient (an informational modifier, does not affect reimbursement)

QK -  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals

QS -  Monitored anesthesia care (an informational modifier, does not affect reimbursement)

QX -  CRNA service with medical direction by a physician

QY -  Medical direction of one CRNA by a physician

QZ -  CRNA service without medical direction by a physician

NOTE: Medicare does not recognize Physical Status P modifiers.

NOTE : Modifier QS versus Modifiers G8 or G9 should be used for Monitored Anesthesia Care.

Anesthesia provider reimbursement

Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.

Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA

service with medical direction by a physician

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the

CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full

payment for the services of each provider are allowed. Documentation must be submitted by

each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ,

CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.

Payment at Medically Supervised Rate

Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are

medically supervised.

How payment calculated for Anesthesia service?

Payment Rules

The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor. The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Participating Conversion Factor = Allowance

• Non-Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ)
(Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%