PAYMENT AND REIMBURSEMENT - Anesthesia

Payment rules

Payment at Medically Supervised RateOnly three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. 

An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised. 

Payment Rules The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor.

The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA)

(Base Units + Time Units) x Participating Conversion Factor = Allowance

• Non-Participating Physician not Medically Directing (Modifier AA) (Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK)

(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK) (Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ) (Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX) (Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

Anesthesia payment reimbursment tips

PAYMENT AND REIMBURSEMENT - Anesthesia

Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.

Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.