Teaching Anesthesiologist service - GC modifier

Anesthesia Services and Teaching Anesthesiologist

If a teaching anesthesiologist is involved in a single procedure with one resident, the anesthesia services will be paid at the personally performed rate. The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure.

The teaching physician’s physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, the anesthesiologist’s services will be paid at the medically directed rate.

Use modifier GC (Teaching Physician Service) to indicate the service has been performed in part by a resident under the direction of a teaching physician. This modifier is added after the anesthesia modifier.

Non-Covered Anesthesia Services

The following anesthesia services are non-covered:
• Stand By

Anesthesia cpt code procedure qualifiying factor and description units.

Procedure Codes and Modifiers

Anesthesia providers are required to utilize the appropriate anesthesia code
identified in the current Relative Value Guide published by the American
Society of Anesthesiologists. Time in attendance should be billed by listing
total minutes

HP will calculate total units by dividing the total minutes (reported in block
24G) by 15, rounding up to the next whole number, and adding the time units
to the auto-loaded base unit values. The base unit values are derived from
the ASARVG for CPT-4 anesthesia codes.

of anesthesia time in block 24G of the CMS-1500 claim form.
Type of service “7” should be used for billing anesthesia codes (00100-
01997). The (837) Institutional electronic claim and the paper claim have
been modified to accept up to four Procedure Code Modifiers. Effective
October 1, 2004 to bill for code 90784, bill the first line item with the code and
one unit. Bill the second line item with code 90784 with modifier 76 (repeat
procedure) and 3 units.

The number of qualifying factor units is multiplied by the price allowed for
anesthesia services. For more information regarding qualifying factors, see
the next section of this manual.

Qualifying Factors
Beginning June 14, 2002, qualifying factors will be reimbursable. Qualifying
factors allow for anesthesia services provided under complicated situations
depending on irregular factors (ex: abnormal risk factors, significant operative
conditions). The qualifying procedures would be reported in conjunction with
the anesthesia procedure code on a separate line item using 1 unit of service.
The qualifying procedure codes are indicated below.

Procedure Code Description Units
99100 Anesthesia for recipient with farthest ages, over
seventy and under one year 1
99116 Complication of anesthesia by utilization of total
body hypothermia 1
99135 Complication of anesthesia by utilization of
controlled hypotension 1
99140 Complication of anesthesia by emergency
conditions 1

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.

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