This is not a CCO study guide.
The question may need updating.
Anesthesia “provision/supervision” modifiers (-AA, -QK, -QY, -QZ, -AD and -QX) explain the role of the anesthesiologist and CRNA. These modifiers are essential for clarifying whether an anesthesia procedure was personally performed, medically directed or medically supervised by an anesthesiologist. Knowing what constitutes medical direction is only part of the challenge. State regulations can create another layer of potential confusion. For example, in some states, Certified Registered Nurse Anesthetists (CRNAs) can work independent of a physician’s medical direction, while other states do not allow such practice.
To ensure compliance, practices should take two steps:
1) discuss what they want to achieve in the operating room (OR) from a strategic standpoint, then
2) make sure physicians understand the appropriate medical direction criteria and that it is clearly documented.For example: A practice in a state where CRNAs cannot work independently might decide it wants its anesthesiologists to provide medical direction of only one CRNA, coded with -QY. Another practice might encourage its anesthesiologists to provide medical direction of two to four concurrent anesthesia procedures, coded with modifier -QK.
To support medical direction,
CMS 100-4, 12 § 50 (C) states physicians must document that they performed each of seven medical direction functions: performed the pre-anesthesia exam and evaluation; prescribed the anesthesia plan; personally took part in the most demanding procedures in the anesthesia plan, including induction and emergence where indicated; ensured any procedures in the anesthesia plan not performed personally were done by a qualified anesthetist; monitored the course of anesthesia administration frequently; was physically present and immediately available for the diagnosis and treatment of emergencies; and provided indicated post-anesthesia care.
It’s important to note that medical direction applies only if a physician oversees four or fewer procedures. Any more than that, and practices must use medical supervision (modifier -AD), as explained in an American Society of Anesthesiologists (ASA)
Timely Topics article.
Payer reimbursement still spearheads practice revenue. Here are three commonly misunderstood aspects of anesthesia coding. Your anesthesia billing staff must understand how to get the revenue you are legally entitled.
www.abeo.com
• QY: Medical direction of one Qualified Nonphysician Anesthetist by an anesthesiologist.
• QK: Medical direction of two, three or four concurrent anesthesia procedures.
2. Medically directed.
a. When the anesthesiologist is involved in specific aspects of anesthesia services
performed by other qualified individuals, the services are considered to be “medically
directed.”
i. Qualified individuals includes: CRNAs, anesthesiologists’ assistants, residents, or
combinations of these individuals.
b. Specific CMS requirements and conditions for medically directed anesthesia services
must be met. (CMS4
)
c. The anesthesiologist may not perform other services while medically directing
anesthesia procedures.
d. Medical direction of one qualified nonphysician anesthesia procedure.
i. Report medical direction of one CRNA anesthesia procedure with modifier QY.
ii. Services submitted with modifier QY will be reimbursed at 50% of the applicable
fee schedule rate.
e. Medical direction of 2-4 concurrent anesthesia procedures.
i. When two to four concurrent anesthesia procedures are medically directed, report
with modifier QK.
ii. Services submitted with modifier QK will be reimbursed at 50% of the applicable
fee schedule rate.
3. Medically supervised.
a. When the anesthesiologist is involved in furnishing more than four procedures
concurrently or is performing other services while directing the concurrent procedures,
the services are considered to be “medically supervised.”
b. CMS standards are used to determine if other services were performed while directing
concurrent procedures. (CMS4
)
c. Report medically supervised anesthesia services with modifier AD.
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d. Services submitted with modifier AD will be reimbursed at the applicable fee schedule
rate for three base units per procedure.
i. No time units will be reimbursed for medically supervised anesthesia services.
ii. Upon written appeal, one 15 minute time unit may be allowed in addition to the
three base units, if the physician submits written documentation showing they
were personally present in addition to the supervised anesthesia provider at the
time of anesthesia induction.
4. Teaching services.
Claims for direction of residents and/or student nurse anesthetists should be submitted
with proper modifiers attached to the anesthesia codes.
a. In order to bill for anesthesia procedures, the teaching physician must be present during
all critical and key portions of the procedure and be immediately available to furnish
services during the entire procedure.
b. Services by the teaching physician when directing a single resident or student nurse:
i. If the teaching physician was directing a resident, report with modifier AA and also
append modifier GC.
ii. If the teaching physician was directing one qualified nonphysician anesthetist (for
example: CRNA, anesthesiologist’s assistant, student), report with modifier QY.
c. Services by the teaching physician when directing two concurrent anesthesia
procedures:
i. If directing two residents performing concurrent cases, report with modifiers AA and
GC.
ii. If directing one resident and one other qualified nonphysician anesthetist
performing concurrent cases:
Report the direction of the resident with modifiers AA and GC.
Report the direction of the qualified nonphysician anesthetist with modifier
QK.
iii. If directing two qualified nonphysician anesthetists performing concurrent cases,
report the direction of both cases with modifier QK.
d. Services by the teaching physician must be submitted with modifier QK when directing
three, or four residents, student nurse anesthetists, or CRNAs concurrently.
e. No reimbursement is made to residents or student nurse anesthetists.
Modifier QX: Qualified nonhysician anesthetist service: With medical direction by a physician
This modifier is reported by the medically directed nurse anesthetist or anesthesiologist assistant. A corresponding claim for medical direction (with the same CPT Anesthesia code with modifier QK or QY) would be submitted by the physician anesthesiologist. Medicare payment for this service is split between the two anesthesia professionals with 50% of the allowed amount paid to the anesthesiologist and 50% to the nurse anesthetist or anesthesiologist assistant.
While not specifically addressed in the Medicare Claims Processing Manual, a QX claim would also match with a claim with the AD modifier.
Modifier QZ: CRNA service: Without medical direction by a physician
This modifier is specific to nurse anesthetists and should not be reported by anesthesiologist assistants. In this scenario, a nurse anesthetist provides care under the supervision of or via a collaborative arrangement with the surgeon of other mode as permitted by state law; medical direction by a physician anesthesiologist is not present.
The nurse anesthetist receives 100% of the allowed amount for cases reported with the QZ modifier. (
Applicable for Medicare, private payers’ policy may vary)
