Thursday, 19 January 2017

CRNA anethesia billing modifiers

Anesthesia Billing for CRNAs

When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors.  

First, the method of reporting claims.  As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services.  Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed” rule to come into play. 

In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service”.   

The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNAs.  According to the January, 2005 Ohio Job and Family Service Physician Handbook, “Services of a hospital employed CRNA/AA are included in the facility.”   

In some cases, Medicare offers small hospitals that employ only one CRNA a “pass through” billing option.  When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital. 

It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.  

Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.  Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.  

Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction.  No time is allowed for any of the concurrent cases.   You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.

The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.  

Obtain state guidelines for each major carrier - Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.
QZ:    (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.   

QX:   (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction. 

QK:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) Medical direction of two, three or four concurrent procedures

QY:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) MD is medically directing one CRNA  

AD:   (physician modifier { used in conjunction with QX modifier} -  pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures

Q6:  (physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source:  HCPCS, 2005.

Hospital and ASC anesthesia billing

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

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

The evolution of the Outpatient Perspective Payment System (OPPS) continues to drastically change the landscape of healthcare reimbursement, both eliminating and creating revenue streams. 

One such revenue stream commonly disregarded by hospitals is anesthetic revenue.  Due to the low dollar value and high volume nature of anesthetic transactions, it historically was difficult to achieve a return on investment of accounts receivable resources.

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

Common result(s) from our service:

* Increased revenue from anesthesia expert resources concentrating on reimbursement for drugs utilized in anesthesia.

* Eliminate subsidization of anesthesia departments.

* Minimized expenditures on drugs by accessing group discount purchasing organizations.

* Monitoring distributor and producer pricing schedules for optimal inventory cost management. 

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

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

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

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

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

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


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