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.