Please note these are dated articles. Up-to-date policies AND CODES should be referenced in conjunction with this information.
Permission is granted to print and share, provided author is credited
Documenting Anesthesia Services
Fall 2019 Communique
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
I’m often asked what kind of documentation is necessary to support anesthesia services. Answers will vary, based on the anesthesia practices unique characteristics. For example, an anesthesia practice that uses a “care team” approach — employing medically directing anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) and Anesthesia Assistant’s (AAs) — will have different requirements than a practice where anesthesiologists personally perform all procedures. Additionally, documentation requirements in a teaching facility are more comprehensive than those in a private anesthesia practice.
Let’s start with basic documentation requirements, and move to alternative examples, as we go.
Basic Documentation Requirements
The National Committee for Quality Assurance (NCQA) publishes 21 elements in its Guidelines for Medical Record Documentation, with six listed as core components; however, not all of the requirements pertain to anesthesia providers (who do not usually have a patient relationship beyond and unrelated to anesthesia services provided for surgical procedures). From this list, basic documentation principals applicable to anesthesia services are as follows:
Pre-Anesthesia Care
In accordance with the ASA Guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medically directing anesthesiologist sign the pre-anesthesia documentation. All of the following guidelines pertain to pre-anesthesia care, with the exception of documented medical emergencies:
The ASA developed Standards for Basic Anesthesia Monitoring in 1986, which were last updated October 28, 2015. Although emergency circumstances and life-saving measures take precedence, the following broad standards apply, with defined methods:
Standards for Post Anesthesia Care were last updated by the ASA on October 15, 2014. They apply to General, Regional, or MAC provided at any location. The standards require all patients, unless specifically ordered otherwise by the anesthesia provider, to be admitted to a Post Anesthesia Care Unit (PACU or equivalent area). The anesthesia provider is responsible for the patient, including support appropriate to the patient’s condition, until patient care is transferred to a PACU nurse.
Reviewing Documentation
Anesthesia record auditors check anesthesia graphs, available on both paper and electronic records, to ensure continuous monitoring by the anesthesia provider, and can confirm the reported anesthesia time several ways.
One method is to review both the documented time along the top of the anesthesia graph and counts the “tick” or monitoring checks as a five-minute increment, based on ASA’s guidelines of monitoring and evaluating the patient’s arterial blood pressure and heart rate at least every five minutes. These monitoring checks should begin shortly after the reported anesthesia start time, and end in proximity to the reported anesthesia stop time, unless documentation supports a delay or complication. Another method compares reported anesthesia times to the Operating Room (OR) circulator and PACU notes. Although these times typically will not match exactly, they should be close to the reported anesthesia times. Time checks are the same for any type of anesthesia practice.
Documentation in the medical record should support specific anesthesia modifiers reported. Anesthesia modifiers were listed on the Office of Inspector General (OIG) Work Plan under “Anesthesia Services – Payments for Personally Performed Services” from 2013 through 2018. Although the report number was removed from the Work Plan last year, it is still important to have an understanding of what each of the modifiers mean in relation to the documentation.
Medical direction modifiers (See Table at end of article) indicate to CMS and other insurers that certain steps have been followed by a medically directing anesthesiologist, as defined in the Medicare Claims Processing Manual (MCPM), under Chapter 12, Section 50, Payment for Anesthesiology Services. Anesthesia practices using the “care team” approach and reporting medical modifiers “QY” or “QK” and “QX” will look for documentation to support the reported modifiers. According to CMS, “Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities.” These are also known as the “seven steps” of medical direction.
“As long as the medically directing anesthesiologist ‘remains physically present and available for immediate diagnosis and treatment of emergencies’ (rule number “vi” of the CMS “seven requirements”), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions:
Placement of a Swan-Ganz catheter, central line or arterial line
Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a ‘to follow case’)
Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.”
However, one is hard pressed to find these answers online now as many of the FAQs have disappeared over the years. Novitas has published, removed and published again a variation of FAQs, which currently indicates as follows:
“An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions, central venous catheter insertions, pulmonary artery catheter insertions, and epidural, spinal, and peripheral nerve blocks) performed in an area immediately available to the operating room when performance of such services does not prevent him/her from being immediately available to respond to the needs of surgical patients.”
This information was last modified July 15, 2019. When you find this kind of information published, keep a copy on your hard drive or print it out to include with your compliance information. As mentioned, when these are no longer available you will have support for following the guidelines.
Any anesthesia practice working with “qualified individuals,” including residents, fellows, CRNAs, AAs, and Student Registered Nurse Anesthetists (SRNAs), should be aware of CMS’s medical direction requirements and exceptions. Many private payer policies have also adopted these guidelines.
Anesthesia practices involved in teaching have additional rules to follow. Information regarding teaching documentation requirements is available in the MCPM under Section 100, Teaching Physician Services. A teaching physician is defined as “A physician (other than another resident) who involves residents in the care of his or her patients.” Anesthesia services furnished in teaching settings are paid under the physician fee schedule if the services are:
• Personally furnished by a physician who is not a resident;
• Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.
If an “AA” modifier or “AA GC” modifiers are reported, documentation must support either personal performance or documented teaching of one or two residents. In my personal experience, electronic anesthesia records (EARs) are helping to improve teaching documentation as EARs clearly identify who was in the room, who provided which service, and typically include legible attestations from the teaching anesthesiologist.
If more than one teaching anesthesiologist worked with the resident, Medicare requires the claim to be filed under the teaching anesthesiologist who started the case, with the GC modifier appended to indicate which services were performed by the resident. CMS does not require a GC modifier for SRNA services because the modifier description pertains only to residents or fellows, depending on the circumstances.
CMS allows a teaching CRNA to report full base and anesthesia time (QZ modifier), under the teaching CRNAs provider number, for two concurrent cases, provided that the teaching CRNA is not medically directed by an anesthesiologist, and the CRNA is present with the SRNA during the pre and post anesthesia care for each case. The CRNA must document her or his involvement with each of the two cases.
Conversely, CMS allows a teaching anesthesiologist to report either personal performance (AA modifier) if she or he is continuously involved in a single case with an SRNA or medical direction (QK modifiers) for two concurrent cases, provided that the steps for medical direction have been followed. In effect, a teaching CRNA may receive full payment for teaching two SRNAs, whereas a teaching anesthesiologist only receives partial payment for their medical direction. No payment is made under Part B for services provided by a SRNA. This is important to keep in mind if a SRNA solely places an arterial line, for example, without the teaching CRNA or anesthesiologist’s involvement.
Depending on your compliance plan or policy, anesthesia practices conduct either internal or external reviews (or a combination of both) to spot-check documentation, as compared to the information sent to CMS or other insurance companies. There are additional areas of documentation concern, some general and some specific to anesthesia. The medical record should support all information provided on an anesthesia claim form, with examples indicated below:
Documentation compliance is more than just an expectation – it is a necessity. Regardless of whether your anesthesia practice has a formal compliance plan, under the Federal Register Publication of the OIG Compliance Program Guidance for Third-Party Medical Billing Companies, the OIG believes that all health care providers should be using internal controls to “more efficiently monitor adherence to applicable statutes, regulations and program requirements.” It is vital providers of anesthesia services understand what information is billed on their behalf and whether they conform to these readily available guidelines.
Table - Anesthesia Modifiers
AA - Anesthesia Services performed personally by the anesthesiologist;
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures;
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition;
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;
QS - Monitored anesthesia care service;
QX - CRNA service; with medical direction by a physician;
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;
QZ - CRNA service: without medical direction by a physician; and
GC - these services have been performed by a resident under the direction of a teaching physician. (The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in §100.1.2. One of the payment modifiers must be used in conjunction with the GC modifier.)
Resources
Link to Communique article: https://www.anesthesiallc.com/publications/communiques/104-communique/past-issues/fall-2019/1256-documenting-anesthesia-services
American Association of Nurse Anesthetists (AANA), Documenting Anesthesia Care, © Copyright 2016
https://cms.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/documenting-anesthesia-care.pdf?sfvrsn=ac0049b1_4
American Society of Anesthesiologists (ASA), Standards and Guidelines
https://www.asahq.org/standards-and-guidelines
Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Non-Physician Practitioners
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
National Committee for Quality Assurance (NCQA), Guidelines for Medical Record Documentation http://www.ncqa.org/portals/0/policyupdates/supplemental/guidelines_medical_record_review.pdf
Office of Inspector General, Work Plan
https://oig.hhs.gov/reports-and-publications/workplan/index.asp
Novitas Solutions (July, 2015) Anesthesia
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00173915
Office of Inspector General, Compliance Guidance, Federal Register / Vol. 63, No. 243 / Friday, December 18, 1998 / Notices
https://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf
Fall 2019 Communique
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
I’m often asked what kind of documentation is necessary to support anesthesia services. Answers will vary, based on the anesthesia practices unique characteristics. For example, an anesthesia practice that uses a “care team” approach — employing medically directing anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) and Anesthesia Assistant’s (AAs) — will have different requirements than a practice where anesthesiologists personally perform all procedures. Additionally, documentation requirements in a teaching facility are more comprehensive than those in a private anesthesia practice.
Let’s start with basic documentation requirements, and move to alternative examples, as we go.
Basic Documentation Requirements
The National Committee for Quality Assurance (NCQA) publishes 21 elements in its Guidelines for Medical Record Documentation, with six listed as core components; however, not all of the requirements pertain to anesthesia providers (who do not usually have a patient relationship beyond and unrelated to anesthesia services provided for surgical procedures). From this list, basic documentation principals applicable to anesthesia services are as follows:
- Each page in the record contains the patient’s name or identification (ID) number;
- All entries in the medical record contain the authors ID. Author ID may be a handwritten signature, unique electronic ID, or initials; (Note: If anesthesia practices are still using paper records, a staff log is recommended for all signatures and initials)
- The record is legible to someone other than the writer.
Pre-Anesthesia Care
In accordance with the ASA Guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medically directing anesthesiologist sign the pre-anesthesia documentation. All of the following guidelines pertain to pre-anesthesia care, with the exception of documented medical emergencies:
- Reviewing the available medical record;
- Interviewing and performing a focused examination of the patient to:
- Discuss medical history, including previous anesthetic experiences and medical therapy.
- Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management.
- Order and review pertinent available tests and consultations as necessary for the delivery of anesthesia care.
- Order appropriate preoperative medications.
- Ensure that consent has been obtained for the anesthesia care AND
- Documenting in the chart that the above has been performed.
The ASA developed Standards for Basic Anesthesia Monitoring in 1986, which were last updated October 28, 2015. Although emergency circumstances and life-saving measures take precedence, the following broad standards apply, with defined methods:
- Standard I – Qualified anesthesia personnel shall be present in the room throughout the conduct of all general and regional anesthetics and monitored anesthesia care (MAC).
- Standard II – During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.
Standards for Post Anesthesia Care were last updated by the ASA on October 15, 2014. They apply to General, Regional, or MAC provided at any location. The standards require all patients, unless specifically ordered otherwise by the anesthesia provider, to be admitted to a Post Anesthesia Care Unit (PACU or equivalent area). The anesthesia provider is responsible for the patient, including support appropriate to the patient’s condition, until patient care is transferred to a PACU nurse.
Reviewing Documentation
Anesthesia record auditors check anesthesia graphs, available on both paper and electronic records, to ensure continuous monitoring by the anesthesia provider, and can confirm the reported anesthesia time several ways.
One method is to review both the documented time along the top of the anesthesia graph and counts the “tick” or monitoring checks as a five-minute increment, based on ASA’s guidelines of monitoring and evaluating the patient’s arterial blood pressure and heart rate at least every five minutes. These monitoring checks should begin shortly after the reported anesthesia start time, and end in proximity to the reported anesthesia stop time, unless documentation supports a delay or complication. Another method compares reported anesthesia times to the Operating Room (OR) circulator and PACU notes. Although these times typically will not match exactly, they should be close to the reported anesthesia times. Time checks are the same for any type of anesthesia practice.
Documentation in the medical record should support specific anesthesia modifiers reported. Anesthesia modifiers were listed on the Office of Inspector General (OIG) Work Plan under “Anesthesia Services – Payments for Personally Performed Services” from 2013 through 2018. Although the report number was removed from the Work Plan last year, it is still important to have an understanding of what each of the modifiers mean in relation to the documentation.
Medical direction modifiers (See Table at end of article) indicate to CMS and other insurers that certain steps have been followed by a medically directing anesthesiologist, as defined in the Medicare Claims Processing Manual (MCPM), under Chapter 12, Section 50, Payment for Anesthesiology Services. Anesthesia practices using the “care team” approach and reporting medical modifiers “QY” or “QK” and “QX” will look for documentation to support the reported modifiers. According to CMS, “Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities.” These are also known as the “seven steps” of medical direction.
- 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;
- Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
- Monitors the course of anesthesia administration at frequent intervals;
- Remains physically present and available for immediate diagnosis and treatment of emergencies; and
- Provides indicated-post-anesthesia care.
- 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 discharge patients in the recovery room; and
- Handling scheduling matters.
-
“As long as the medically directing anesthesiologist ‘remains physically present and available for immediate diagnosis and treatment of emergencies’ (rule number “vi” of the CMS “seven requirements”), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions:
Placement of a Swan-Ganz catheter, central line or arterial line
Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a ‘to follow case’)
Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.”
However, one is hard pressed to find these answers online now as many of the FAQs have disappeared over the years. Novitas has published, removed and published again a variation of FAQs, which currently indicates as follows:
“An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions, central venous catheter insertions, pulmonary artery catheter insertions, and epidural, spinal, and peripheral nerve blocks) performed in an area immediately available to the operating room when performance of such services does not prevent him/her from being immediately available to respond to the needs of surgical patients.”
This information was last modified July 15, 2019. When you find this kind of information published, keep a copy on your hard drive or print it out to include with your compliance information. As mentioned, when these are no longer available you will have support for following the guidelines.
Any anesthesia practice working with “qualified individuals,” including residents, fellows, CRNAs, AAs, and Student Registered Nurse Anesthetists (SRNAs), should be aware of CMS’s medical direction requirements and exceptions. Many private payer policies have also adopted these guidelines.
Anesthesia practices involved in teaching have additional rules to follow. Information regarding teaching documentation requirements is available in the MCPM under Section 100, Teaching Physician Services. A teaching physician is defined as “A physician (other than another resident) who involves residents in the care of his or her patients.” Anesthesia services furnished in teaching settings are paid under the physician fee schedule if the services are:
• Personally furnished by a physician who is not a resident;
• Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.
If an “AA” modifier or “AA GC” modifiers are reported, documentation must support either personal performance or documented teaching of one or two residents. In my personal experience, electronic anesthesia records (EARs) are helping to improve teaching documentation as EARs clearly identify who was in the room, who provided which service, and typically include legible attestations from the teaching anesthesiologist.
If more than one teaching anesthesiologist worked with the resident, Medicare requires the claim to be filed under the teaching anesthesiologist who started the case, with the GC modifier appended to indicate which services were performed by the resident. CMS does not require a GC modifier for SRNA services because the modifier description pertains only to residents or fellows, depending on the circumstances.
CMS allows a teaching CRNA to report full base and anesthesia time (QZ modifier), under the teaching CRNAs provider number, for two concurrent cases, provided that the teaching CRNA is not medically directed by an anesthesiologist, and the CRNA is present with the SRNA during the pre and post anesthesia care for each case. The CRNA must document her or his involvement with each of the two cases.
Conversely, CMS allows a teaching anesthesiologist to report either personal performance (AA modifier) if she or he is continuously involved in a single case with an SRNA or medical direction (QK modifiers) for two concurrent cases, provided that the steps for medical direction have been followed. In effect, a teaching CRNA may receive full payment for teaching two SRNAs, whereas a teaching anesthesiologist only receives partial payment for their medical direction. No payment is made under Part B for services provided by a SRNA. This is important to keep in mind if a SRNA solely places an arterial line, for example, without the teaching CRNA or anesthesiologist’s involvement.
Depending on your compliance plan or policy, anesthesia practices conduct either internal or external reviews (or a combination of both) to spot-check documentation, as compared to the information sent to CMS or other insurance companies. There are additional areas of documentation concern, some general and some specific to anesthesia. The medical record should support all information provided on an anesthesia claim form, with examples indicated below:
- Provider of medical service or services.
- Diagnosis and procedure codes.
- Anesthesia times, including documented discontinuous anesthesia time and any case relief or transfer of patient care – this is particularly important if your state Medicaid has a face-to-face policy for reporting labor epidural services.
- General, Regional or Monitored Anesthesia (MAC) – CMS and other insurance companies may have medical necessity policy and/or require a QS, G8 or G9 modifier when MAC is provided.
- Indication of physician or teaching CRNA presence at induction, emergence and other “demanding” procedures – note that induction and emergence are not applicable to regional or MAC, although documentation of presence during initiation or placement may apply.
- Procedure notes for invasive monitoring lines and/or other “surgical” procedures, including who provided the service and when – time notations allow coders to determine when blocks or catheters are placed and whether discontinuous time is applicable. Keep in mind that these “surgical” procedures (such as an arterial line) are not “medically directed or supervised”, which only pertains to anesthesia services.
- Surgeon’s request for post-operative pain management, when applicable.
- Qualifying circumstances, such as an emergency*.
- Physical status, such as a patient with a severe systemic disease*.
Documentation compliance is more than just an expectation – it is a necessity. Regardless of whether your anesthesia practice has a formal compliance plan, under the Federal Register Publication of the OIG Compliance Program Guidance for Third-Party Medical Billing Companies, the OIG believes that all health care providers should be using internal controls to “more efficiently monitor adherence to applicable statutes, regulations and program requirements.” It is vital providers of anesthesia services understand what information is billed on their behalf and whether they conform to these readily available guidelines.
Table - Anesthesia Modifiers
AA - Anesthesia Services performed personally by the anesthesiologist;
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures;
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition;
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;
QS - Monitored anesthesia care service;
QX - CRNA service; with medical direction by a physician;
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;
QZ - CRNA service: without medical direction by a physician; and
GC - these services have been performed by a resident under the direction of a teaching physician. (The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in §100.1.2. One of the payment modifiers must be used in conjunction with the GC modifier.)
Resources
Link to Communique article: https://www.anesthesiallc.com/publications/communiques/104-communique/past-issues/fall-2019/1256-documenting-anesthesia-services
American Association of Nurse Anesthetists (AANA), Documenting Anesthesia Care, © Copyright 2016
https://cms.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/documenting-anesthesia-care.pdf?sfvrsn=ac0049b1_4
American Society of Anesthesiologists (ASA), Standards and Guidelines
https://www.asahq.org/standards-and-guidelines
Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Non-Physician Practitioners
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
National Committee for Quality Assurance (NCQA), Guidelines for Medical Record Documentation http://www.ncqa.org/portals/0/policyupdates/supplemental/guidelines_medical_record_review.pdf
Office of Inspector General, Work Plan
https://oig.hhs.gov/reports-and-publications/workplan/index.asp
Novitas Solutions (July, 2015) Anesthesia
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00173915
Office of Inspector General, Compliance Guidance, Federal Register / Vol. 63, No. 243 / Friday, December 18, 1998 / Notices
https://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf
The Winning Strategy for Billing Invasive Monitoring
Wednesday, 08 August 2018
When the ASA Relative Value Guide (RVG) was first developed in the 1970s it established a significant precedent with regard to what services could be billed as incidental to an anesthetic. The guide established the concept of "invasive" as the critical criterion.
Arterial artery catheters, known as A-lines; central venous catheters; and Swan-Ganz catheters were specifically identified as non-bundled services because they were used for particularly sick patients with a high risk factor and were invasive. Some years later transesophageal echocardiography (TEE) was also added to the list, even though it was not technically invasive. One might also say that ultrasonic guidance for vascular line placement has also been lumped into the same category.
This distinction has served the specialty well ever since, especially since virtually all payer fee schedules include payment for these "surgical" services, i.e., the placement of such devices. Where anesthesia providers need to be careful, though, is in ensuring that their clinical documentation completely supports a charge for each service. The requirements and exclusions are specific.
The Nuances of 'Who 'The first question is always who provided the service? This might seem obvious, but it is not always clear whether the anesthesia provider simply took advantage of an in situ catheter. In some facilities, surgeons or a perfusionist may place catheters for monitoring cardiovascular function, in which case the placement of such devices is a non-billable event for the anesthesia provider.
If more than one anesthesia staff member is signed into the case—a combination of anesthesiologist, teaching anesthesiologist and resident, certified registered nurse anesthetist (CRNA) or student registered nurse anesthetist (SRNA)—documentation must clearly show who placed the line. Teaching rules have special requirements for documentation of physician participation, and although a GC modifier indicates "when the service has been performed in part by a resident under the direction of a teaching physician," there is no modifier to report an SRNA placing a line. Indeed, no payment is made under Medicare Part B for services provided by an SRNA. This is important to keep in mind if an SRNA solely places an arterial line, for example, without the teaching CRNA's or anesthesiologist's documented involvement.
Although an auditor is not likely to request all the records prepared by the various staff in an operating room, they might if there were a question regarding the accuracy or completeness of the anesthesia record. Ideally, any notes prepared by the OR staff should conform to the anesthesia record.
Why and How? Why and how was such monitoring administered? Unlike the calculation of the anesthesia charge itself, the placement of invasive monitoring is billed as surgical services. No time is involved. And payment is based on a surgical fee schedule. Although a full operative report is not necessary or expected, the medical record documentation for these ancillary services must explain the details of the procedure and its relevance to the patient's condition.
While the advent of electronic anesthesia records (EARs) has helped tremendously with clear documentation of these services, paper anesthesia records do not typically have enough room under the Remarks or Comments areas to fully describe ancillary services. The best practice for anesthesia providers is to utilize a separate procedure note, which will allow enough room to include documentation required under The Joint Commission's Universal Protocol (see resources at the end of this article).
This protocol requires a date of service, patient's name and consent, start and end time of the procedure, medical necessity (reason for insertion), a description of supplies used, a procedural "timeout" (correct patient identity, correct site, procedure to be done), patient's positioning, preparation for the procedure, confirmation of using sterile technique (sterile gloves, gown, hat/cap, mask, full body drape and, if ultrasound is used, sterile gel and probe covers), confirmation of the insertion site, a full description of the procedure (including whether the line was removed with the tip intact, when applicable) and whether ultrasound was utilized. The form must also include the anesthesia provider's legible signature.
Keep in mind that documentation of the use of ultrasound alone is not sufficient. According to CPT® non-obstetrical ultrasound coding guidelines, "Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable." Although it does not normally need to be turned in with your billing records, a retrievable image must be available in the medical records, along with the signed procedure note describing the use of ultrasound, when applicable.
Clearly, a check box on the anesthesia record under monitors and equipment, or "Swan-Ganz" written in the remarks section, does not meet these Universal Protocol standards.
Clarity and Communication Your documentation must be clear enough that coders can determine, without asking for additional information, whether a pulmonary artery catheter was floated through an existing line or whether it was medically necessary to place separate lines. Your staff or billing partners must be able to determine whether additional indicated services are billable. There should be continuously open lines of communication between the coding/billing office and the clinical staff. If the information or documentation turned in for billing is not clear, questions should be asked and answered. Delayed billing while waiting for either a response or additional documentation is better than not capturing payment for your service. Educate your staff on what to look for in your practice.
Capturing these services, however, is only half the battle. Keeping or receiving payment for these services when documentation is requested is the other half of a winning strategy. It is a good idea to review the payments you are receiving for monitoring services on a periodic basis, as payers may implement new payment edits unexpectedly.
Resources
ASA 2018 Relative Value Guide® http://www.asahq.org/
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6706.pdf
https://www.jointcommission.org/assets/1/18/UP_Poster.pdf
http://www.anesthesiallc.com/publications/blog/entry/the-winning-strategy-for-billing-invasive-monitoring
Winter 2016 Communique
2016 Coding Updates for Anesthesia
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/component/content/article/89-communique/current-issue/winter2016/861-2016-coding-updates-for-anesthesia
Wednesday, 08 August 2018
When the ASA Relative Value Guide (RVG) was first developed in the 1970s it established a significant precedent with regard to what services could be billed as incidental to an anesthetic. The guide established the concept of "invasive" as the critical criterion.
Arterial artery catheters, known as A-lines; central venous catheters; and Swan-Ganz catheters were specifically identified as non-bundled services because they were used for particularly sick patients with a high risk factor and were invasive. Some years later transesophageal echocardiography (TEE) was also added to the list, even though it was not technically invasive. One might also say that ultrasonic guidance for vascular line placement has also been lumped into the same category.
This distinction has served the specialty well ever since, especially since virtually all payer fee schedules include payment for these "surgical" services, i.e., the placement of such devices. Where anesthesia providers need to be careful, though, is in ensuring that their clinical documentation completely supports a charge for each service. The requirements and exclusions are specific.
The Nuances of 'Who 'The first question is always who provided the service? This might seem obvious, but it is not always clear whether the anesthesia provider simply took advantage of an in situ catheter. In some facilities, surgeons or a perfusionist may place catheters for monitoring cardiovascular function, in which case the placement of such devices is a non-billable event for the anesthesia provider.
If more than one anesthesia staff member is signed into the case—a combination of anesthesiologist, teaching anesthesiologist and resident, certified registered nurse anesthetist (CRNA) or student registered nurse anesthetist (SRNA)—documentation must clearly show who placed the line. Teaching rules have special requirements for documentation of physician participation, and although a GC modifier indicates "when the service has been performed in part by a resident under the direction of a teaching physician," there is no modifier to report an SRNA placing a line. Indeed, no payment is made under Medicare Part B for services provided by an SRNA. This is important to keep in mind if an SRNA solely places an arterial line, for example, without the teaching CRNA's or anesthesiologist's documented involvement.
Although an auditor is not likely to request all the records prepared by the various staff in an operating room, they might if there were a question regarding the accuracy or completeness of the anesthesia record. Ideally, any notes prepared by the OR staff should conform to the anesthesia record.
Why and How? Why and how was such monitoring administered? Unlike the calculation of the anesthesia charge itself, the placement of invasive monitoring is billed as surgical services. No time is involved. And payment is based on a surgical fee schedule. Although a full operative report is not necessary or expected, the medical record documentation for these ancillary services must explain the details of the procedure and its relevance to the patient's condition.
While the advent of electronic anesthesia records (EARs) has helped tremendously with clear documentation of these services, paper anesthesia records do not typically have enough room under the Remarks or Comments areas to fully describe ancillary services. The best practice for anesthesia providers is to utilize a separate procedure note, which will allow enough room to include documentation required under The Joint Commission's Universal Protocol (see resources at the end of this article).
This protocol requires a date of service, patient's name and consent, start and end time of the procedure, medical necessity (reason for insertion), a description of supplies used, a procedural "timeout" (correct patient identity, correct site, procedure to be done), patient's positioning, preparation for the procedure, confirmation of using sterile technique (sterile gloves, gown, hat/cap, mask, full body drape and, if ultrasound is used, sterile gel and probe covers), confirmation of the insertion site, a full description of the procedure (including whether the line was removed with the tip intact, when applicable) and whether ultrasound was utilized. The form must also include the anesthesia provider's legible signature.
Keep in mind that documentation of the use of ultrasound alone is not sufficient. According to CPT® non-obstetrical ultrasound coding guidelines, "Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable." Although it does not normally need to be turned in with your billing records, a retrievable image must be available in the medical records, along with the signed procedure note describing the use of ultrasound, when applicable.
Clearly, a check box on the anesthesia record under monitors and equipment, or "Swan-Ganz" written in the remarks section, does not meet these Universal Protocol standards.
Clarity and Communication Your documentation must be clear enough that coders can determine, without asking for additional information, whether a pulmonary artery catheter was floated through an existing line or whether it was medically necessary to place separate lines. Your staff or billing partners must be able to determine whether additional indicated services are billable. There should be continuously open lines of communication between the coding/billing office and the clinical staff. If the information or documentation turned in for billing is not clear, questions should be asked and answered. Delayed billing while waiting for either a response or additional documentation is better than not capturing payment for your service. Educate your staff on what to look for in your practice.
Capturing these services, however, is only half the battle. Keeping or receiving payment for these services when documentation is requested is the other half of a winning strategy. It is a good idea to review the payments you are receiving for monitoring services on a periodic basis, as payers may implement new payment edits unexpectedly.
Resources
ASA 2018 Relative Value Guide® http://www.asahq.org/
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6706.pdf
https://www.jointcommission.org/assets/1/18/UP_Poster.pdf
http://www.anesthesiallc.com/publications/blog/entry/the-winning-strategy-for-billing-invasive-monitoring
Winter 2016 Communique
2016 Coding Updates for Anesthesia
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/component/content/article/89-communique/current-issue/winter2016/861-2016-coding-updates-for-anesthesia
Winter 2014 Communique
Reporting Postoperative Pain Management in 2014
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/index.php/publications/communique?id=679
Reporting Postoperative Pain Management in 2014
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
http://www.anesthesiallc.com/index.php/publications/communique?id=679
AAPC Articles may require membership to access
March, 2017, Healthcare Business Monthly, Quality Reporting for Anesthesia Services: Then and Now
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
www.aapc.com/blog/37862-quality-reporting-for-anesthesia-services-then-and-now/
September, 2013, AAPC Coding Edge, Managing Post Operative Pain is a Joint Effort
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2013/09/managing-postoperative-pain-is-a-joint-effort/
February, 2011 AAPC Coding Edge, Understand Payer Guidelines to Keep Up-to-date with Anesthesia
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2011/02/understand-payer-guidelines-to-keep-up-to-date-with-anesthesia/
August, 2009 AAPC Coding Edge, Draw a line between Moderate (Conscious) Sedation and Monitored Anesthesia Care
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
https://www.aapc.com/blog/25598-draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
www.aapc.com/blog/37862-quality-reporting-for-anesthesia-services-then-and-now/
September, 2013, AAPC Coding Edge, Managing Post Operative Pain is a Joint Effort
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2013/09/managing-postoperative-pain-is-a-joint-effort/
February, 2011 AAPC Coding Edge, Understand Payer Guidelines to Keep Up-to-date with Anesthesia
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
http://news.aapc.com/index.php/2011/02/understand-payer-guidelines-to-keep-up-to-date-with-anesthesia/
August, 2009 AAPC Coding Edge, Draw a line between Moderate (Conscious) Sedation and Monitored Anesthesia Care
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
https://www.aapc.com/blog/25598-draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/
November/December 2005 Nancy Maguire's Coding & Billing Expert
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 CRNA’s 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.
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 CRNA’s. 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 CRNA’s are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.
In most instances, CRNA’s 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 CRNA’s.Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.
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 CRNA’s.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
By: Kelly Dennis, MBA, ACS-AP, CPC
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 CRNA’s 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.
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 CRNA’s. 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 CRNA’s are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.
In most instances, CRNA’s 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 CRNA’s.Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.
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 CRNA’s.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
By: Kelly Dennis, MBA, ACS-AP, CPC
MGMA E-Connextion, Issue 86, October 2005
Internal audits
Many practices are too busy with day-to-day work to keep track of how often they should conduct internal audits. However, if your practice has a compliance plan, it generally outlines the required audit frequency. Do you know what your compliance plan requires?
If your anesthesiology practice is using the standard compliance plan outline published by the American Society of Anesthesiologists in Compliance With Medicare and Other Payor Billing Requirements, your practice is required to review pre-submission (claims reviewed before filing to the insurance carrier) on a quarterly basis, and post-submission (claims reviewed after filing to the insurance carrier) at regular intervals, such as semiannually.
Having anesthesia records available as you start your internal audit can make an internal audit easier. If anesthesia records are not available, obtain them from the hospital.
An internal audit is simply an objective review of the anesthesia services billed to monitor the accuracy of claims. It
should be performed by a qualified employee – such as the office administrator, manager, certified coder (other than the employee who coded the services), the compliance officer, a physician, or a combination. Each practice determines the number of charges or percentage of claims to be reviewed for each provider. It also determines how to make appropriate corrections and, depending on the internal audit results, whether to contact legal counsel. Although the standard compliance plan requires the practice to undertake all claims monitoring with legal counsel, the practice may modify the plan to require legal counsel consultation only during external audits.
A simple pre-submission review should compare the codes and modifiers billed with the documentation on file. Because the auditor reviews this information before submitting the claim, corrections are made during the review process and corrective actions should be taken and conveyed to staff. For example, a review determined the coder mistook “TKA” for a total knee arthroscopy (01400 base value - 4) rather than total knee arthroplasty (01402 base value -7). The practice must take several corrective steps:
1) Change code, if applicable.Different physicians may be using different acronyms;
2) Ensure acronyms in your practice are clearly defined; and
3) Request a report of 01400 and 01402 claims filed within the past 18 months to verify accuracy.
Post-submission review is more complex and should include a review through resolution. Choose a date within the past six months, and in addition to checking codes and modifiers used, review payment processes to ensure correct reimbursement and appropriate adjustments were made. Each practice should know exactly what payment to expect. Medicare pays by location and the amount is standard; other payers may be contracted using various amount and time calculation techniques so a matrix of expected reimbursement is helpful.At the very least, a form listing annual expected amounts is necessary.
An important area to review is concurrency and documentation of medical direction criteria. Depending on your software concurrency reporting capabilities, it may be necessary to review an entire day of concurrency if your practice includes residents, certified registered nurse anesthetists, anesthesia assistants, or student registered nurse anesthetists. It is important to understand that concurrency calculations must include all patients, regardless of
insurance. While some carriers allow a combination of up to four concurrent cases, graduate medical rules differ and allow up to two cases when residents or SRNA’s are involved.
Whether conducting a pre- or post-submission review, keep documentation of all steps taken in a compliance file. Even if your practice only reviews once a year, make certain the time frame agrees with the written compliance plan. The adage, “It is better not to have a compliance plan, than to have one and not follow it,” is particularly true for anesthesia practices, as anesthesia billing rules are often vague and ambiguous.
By Kelly D. Dennis, kellyddennis@attglobal.net, MGMA member and president, Perfect Office Solutions, Leesburg, Fla.
Internal audits
Many practices are too busy with day-to-day work to keep track of how often they should conduct internal audits. However, if your practice has a compliance plan, it generally outlines the required audit frequency. Do you know what your compliance plan requires?
If your anesthesiology practice is using the standard compliance plan outline published by the American Society of Anesthesiologists in Compliance With Medicare and Other Payor Billing Requirements, your practice is required to review pre-submission (claims reviewed before filing to the insurance carrier) on a quarterly basis, and post-submission (claims reviewed after filing to the insurance carrier) at regular intervals, such as semiannually.
Having anesthesia records available as you start your internal audit can make an internal audit easier. If anesthesia records are not available, obtain them from the hospital.
An internal audit is simply an objective review of the anesthesia services billed to monitor the accuracy of claims. It
should be performed by a qualified employee – such as the office administrator, manager, certified coder (other than the employee who coded the services), the compliance officer, a physician, or a combination. Each practice determines the number of charges or percentage of claims to be reviewed for each provider. It also determines how to make appropriate corrections and, depending on the internal audit results, whether to contact legal counsel. Although the standard compliance plan requires the practice to undertake all claims monitoring with legal counsel, the practice may modify the plan to require legal counsel consultation only during external audits.
A simple pre-submission review should compare the codes and modifiers billed with the documentation on file. Because the auditor reviews this information before submitting the claim, corrections are made during the review process and corrective actions should be taken and conveyed to staff. For example, a review determined the coder mistook “TKA” for a total knee arthroscopy (01400 base value - 4) rather than total knee arthroplasty (01402 base value -7). The practice must take several corrective steps:
1) Change code, if applicable.Different physicians may be using different acronyms;
2) Ensure acronyms in your practice are clearly defined; and
3) Request a report of 01400 and 01402 claims filed within the past 18 months to verify accuracy.
Post-submission review is more complex and should include a review through resolution. Choose a date within the past six months, and in addition to checking codes and modifiers used, review payment processes to ensure correct reimbursement and appropriate adjustments were made. Each practice should know exactly what payment to expect. Medicare pays by location and the amount is standard; other payers may be contracted using various amount and time calculation techniques so a matrix of expected reimbursement is helpful.At the very least, a form listing annual expected amounts is necessary.
An important area to review is concurrency and documentation of medical direction criteria. Depending on your software concurrency reporting capabilities, it may be necessary to review an entire day of concurrency if your practice includes residents, certified registered nurse anesthetists, anesthesia assistants, or student registered nurse anesthetists. It is important to understand that concurrency calculations must include all patients, regardless of
insurance. While some carriers allow a combination of up to four concurrent cases, graduate medical rules differ and allow up to two cases when residents or SRNA’s are involved.
Whether conducting a pre- or post-submission review, keep documentation of all steps taken in a compliance file. Even if your practice only reviews once a year, make certain the time frame agrees with the written compliance plan. The adage, “It is better not to have a compliance plan, than to have one and not follow it,” is particularly true for anesthesia practices, as anesthesia billing rules are often vague and ambiguous.
By Kelly D. Dennis, kellyddennis@attglobal.net, MGMA member and president, Perfect Office Solutions, Leesburg, Fla.