Anesthesia Billing for CRNAs

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 CRNAs. 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 CRNAs are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.

In most instances, CRNAs 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 CRNAs. 

Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.

base units of Anesthesia cpt code - list 2

CPT CODES and BASE UNITS

CPT CODES and BASE UNITS

00930 4 00932 4 00934 6 00936 8 00938 4 00940 3 00942 4 00944 6 00948 4 00950 5 00952 4 01112 5 01120 6 01130 3 01140 15 01150 10 01160 4 01170 8 01173 12 01180 3 01190 4 01200 4 01202 4 01210 6 01212 10 01214 8 01215 10 01220 4 01230 6 01232 5 01234 8 01250 4 01260 3 01270 8 01272 4 01274 6 01320 4 01340 4 01360 5 01380 3 01382 3 01390 3 01392 4 01400 4 01402 7 01404 5 01420 3 01430 3 01432 6 01440 8 01442 8 01444 8 01462 3 01464 3 01470 3 01472 5 01474 5 01480 3 01482 4 01484 4 01486 7 01490 3 01500 8 01502 6 01520 3 01522 5 01610 5 01620 4 01622 4 01630 5 01634 9 01636 15 01638 10 01650 6 01652 10 01654 8 01656 10 01670 4 01680 3 01682 4 01710 3 01712 5 01714 5 01716 5 01730 3 01732 3 01740 4 01742 5 01744 5 01756 6 01758 5 01760 7 01770 6 01772 6 01780 3 01782 4 01810 3 01820 3 01829 3 01830 3 01832 6 01840 6 01842 6 01844 6 01850 3 01852 4 01860 3 01916 5 01920 7 01922 7 01924 6 01925 8 01926 10 01930 5 01931 7 01932 7 01933 8 01935 5 01936 5 01951 3 01952 5 + 01953 1 01958 5 01960 5 01961 7 01962 8 01963 10 01965 4 01966 4 01969 5 01990 7 01991 3 01992 5

00100 5 00102 6 00103 5 00104 4 00120 5 00124 4 00126 4 00140 5 00142 6 00144 6 00145 6 00147 6 00148 4 00160 5 00162 7 00164 4 00170 5 00172 6 00174 6 00176 7 00190 5 00192 7 00210 11 00211 10 00212 5 00214 9 00215 9 00216 15 00218 13 00220 10 00222 6 00300 5 00320 6 00322 3 00326 8 00350 10 00352 5 00400 3 00402 5 00404 5 00406 13 00410 4 00450 5 00452 6 00454 3 00470 6  00472 10 00474 13 00500 15 00520 6 00522 4 00524 4 00528 8 00529 11 00530 4 00532 4 00534 7 00537 10 00539 18 00540 12 00541 15 00542 15 00546 15 00548 17 00550 10 00560 15 00561 25 00562 20 00563 25 00567 18 00566 25 00580 20 00600 10 00604 13 00620 10 00622 13 00625 13 00626 15 00630 8 00632 7 00634 10 00635 4 00640 3 00670 13 00700 4 00702 4 00730 5 00740 5 00750 4 00752 6 00754 7 00756 7 00770 15 00790 7 00792 13 00794 8 00796 30 00797 11 00800 4 00802 5 00810 5 00820 5 00830 4 00832 6 00834 5 00836 6 00840 6 00842 4 00844 7 00846 8 00848 8 00851 6 00860 6 00862 7 00864 8 00865 7 00866 10 00868 10 00870 5 00872 7 00873 5 00880 15 00882 10 00902 5 00904 7 00906 4 00908 6 00910 3 00912 5 00914 5 00916 5 00918 5 00920 3 00921 3 00922 6 00924 4 00926 4 00928 6

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 info@anestheticbilling.com 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.

Risk and complication of anesthesia

Anesthesia - Risks and Complications

Although all types of anesthesia involve some risk, major side effects and complications from anesthesia are uncommon. Your specific risks depend on your health, the type of anesthesia used, and your response to anesthesia. Personal risk factors Your age may be a risk factor. In general, the risks associated with anesthesia and surgery increase in older people.

Certain medical conditions, such as heart, circulation, or nervous system problems, increase your risk of complications from anesthesia.

Some medicines can raise your risk of problems too. Make a list of all the prescription and over-the-counter medicines you take. And share your list with your doctors.

If you smoke, drink alcohol, or use illegal drugs, you may be more likely to have problems from anesthesia. It's important that you are honest when you talk with your surgeon and anesthesia specialist.

Anesthesia specialists, anesthesiologist and Anesthetist definition

Anesthesia specialists

Anesthesia specialists are responsible for making informed medical decisions to provide comfort and maintain vital life functions while you are receiving anesthesia and in recovery.

Anesthesia specialists include anesthesiologists and qualified nurse or dental anesthetists.

Anesthesiologist

Anesthesiologists are medical doctors who, after obtaining their medical degree and completing their internship, complete an additional 3 years of specialized training in an accredited anesthesiology residency program. They are certified by the American Board of Anesthesiology. As medical doctors, they have a wide range of knowledge about medications, medical care for diseases, how the human body works, and how it responds to the stress of surgery. 

Anesthetist

Most anesthetists are nurses who have graduated from an accredited nurse anesthetist program and who have been certified by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). Nurse anesthetists are advanced practice nurses with specialized skills in anesthesia administration. A nurse anesthetist is usually supervised by an anesthesiologist or a surgeon, although law and practice may vary by state.

ANESTHESIOLOGIST DIRECTED ANESTHESIA

Medical direction may apply to a single anesthesia service furnished by a CRNA or up to four concurrent anesthesia services. A physician who is directing the administration of anesthesia to four surgical members is not expected to be involved routinely in furnishing any additional services to other members. 

Addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic rather than continual monitoring of an obstetrical member would not substantially diminish the physician’s capacity to direct the CRNA services.

The medical directing anesthesiologist must document in the member’s medical record that all medical direction requirements have been met, including:

• Perform the pre-anesthetic examination and evaluation

• Prescribe the anesthesia plan

• Participate personally in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence

• Ensure a qualified individual performs any procedure in the anesthesia plan he/she does not perform personally

• Monitor the course of anesthesia administration at frequent intervals

• Remain physically present and available for immediate diagnosis and treatment of emergency that may develop

• Provide indicated post-anesthesia care.

A physician may appropriately receive members entering the operating suite for the next surgery while directing concurrent anesthesia procedures. 

However, checking or discharging members in the recovery room and handling scheduling matters are not compatible with reimbursement to the physician for directing concurrent anesthesia procedures.

PCA - Patient Controlled Analgesia

Patient Controlled Analgesia

Patient controlled analgesia (PCA) services are reimbursable when they are administered by an anesthesiologist and are performed for the control of postoperative pain. A separately identifiable physician-recipient encounter should be reflected in the medical record documentation. PCA pumps are usually administered through an intravenous (IV) line or the PCA pump is connected to an epidural catheter line.

Daily management of a PCA pump through an IV line is disallowed. When an anesthesiologist provides the management of the PCA pump through an IV line, the anesthesiologist will be allowed a total of four units and will be considered a global payment for the management regardless of the number of days the recipient remains on the pump. Use procedure code 90784 for daily hospital management of intravenous patient-controlled analgesia.

The anesthesiologist should use the appropriate procedure code(s) when filing claims for a single injection or for an injection including catheter placement (epidural, subarachnoid, cervical, thoracic, lumbar, or sacral) when the PCA pump is connected to an epidural line. 

Placement of the epidural catheter and daily management of a subarachnoid or epidural catheter is not reimbursable on the same date of service. Daily management of a subarachnoid or epidural catheter is reimbursable on subsequent days.

Delivery of pain medication through intermittent injections, a regular infusion, or by a PCA pump is included in the management of an epidural line whether a registered nurse or a physician administers it. Additional units for a PCA pump that is connected to an epidural line is not separately reimbursable.

The global surgical reimbursement fee to the surgeon includes the management of a PCA pump for post-operative pain control and is not a separately reimbursable item. 

Similarly, a physician’s global medical service reimbursement includes the management of a PCA pump for recipients with chronic pain control or terminal cancer and is not separately reimbursable.

Biling and coding tip for anesthesia CPT codes

CPT Anesthesia Code List

00100–00222 Head

00100 Anesthesia for procedures on salivary glands, including biopsy

00102 Anesthesia for procedures on plastic repair of cleft lip

Coding Tip

Do not use code 00102 for procedures performed on the lip for conditions other than repair of cleft lip. For other, non-cleft lip repairs, see code 00300.

For cleft palate repairs, see 00172.

00103 Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery)

00104 Anesthesia for electroconvulsive therapy

Coding Tip

Code 00104 may be denied when multiple electroconvulsive therapy (ECT) is provided. ECT (CPT code 90871) is a noncovered service by Medicare. Therefore, when anesthesia is performed for this reason, it will be denied as such.

00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

00124 otoscopy

00126 tympanotomy

Coding Tip

Codes 00120–00126 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00140 Anesthesia for procedures on eye; not otherwise specified

00142 lens surgery

00144 corneal transplant

Coding Tip

Codes 00140–00144 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00145 Anesthesia for procedures on eye; vitreoretinal surgery

Coding Tip

Code 00145 is for a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

This code is appropriate to use on any vitreoretinal procedures requiring the same anesthetic management.

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified

00162 radical surgery

00164 biopsy, soft tissue

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

Coding Tip:

Diagnosis coding is important to substantiate coverage of code 00170.

Anesthesia provided in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth is noncovered by Medicare.

J codes J0120–J9999 Drugs Administered Including Oral and Chemotherapy Drugs

K codes K0001–K9999 Durable Medical Equipment Prosthetics, Orthotics, Supplies and Dressings (DMEPOS)

L codes L0100–L9999 Orthotic and Prosthetic Procedures, Devices

M codes M0064–M9999 Medical Services

P codes P2028–P9999 Pathology and Laboratory Services

Q codes Q0035–Q9999 Miscellaneous Services (Temporary Codes)

R codes R0070–R9999 Radiology Services

T codes T1000–T9999 Medical Services

S codes S0009–S9999 Commercial Payers (Temporary Codes)

V codes V2020–V9999 Vision, Hearing and Speech- Language Pathology Services

Get More Patients for Your Medical Practice

When medical students are concentrating on preparing for anatomy tests and attempting to remember endless lists of diseases and conditions, I doubt the thought of “How will I get patients in my door?” ever crosses their minds.

I read a blog the other day with a few suggestions on how hospitals should utilize their website to bring patients in to their facility. 

There are usually not hospitals on every corner whereas, it can seem like you can’t throw something and miss a physician’s office. 

This increases the competition for patient business exponentially over that of hospitals.  So if a “business machine” like a hospital needs help with their “web presence” to entice patients, private practice physicians must be in dire straits in that department.

The suggestions posted for hospitals were: provide a toll-free customer support number, add trust indicators, and include testimonials.

I think with some minor adaptations we can follow their reasoning and come up with some good suggestions to increase the flow of customers to your medical practice.

I do not see any advantage to a toll-free number, but a prominently displayed contact number and address with available directions is very important content for your website.

I also suggest avoiding the “press a number for your party and leave a message” as the only option with your automated telephone answering system.  People like to speak to humans, always have this as an option.                                                                                                                                                         

Your credentials are another highly valuable addition to your website. At the bare minimum, provide details of your professional degrees as well as internship, fellowship and residency completions.  Patients are interested in their physicians’ training and will have increased confidence when able to easily see this information.

You can really impress patients by also including any medical publications you have authored, lectures or teaching participations, etc.  It’s perfectly okay to boast a little, be proud of the knowledge and expertise that you can provide for your patients.

When patients love their doctor, they love to tell other people.  If you have some particularly enthusiast patients, go ahead, ask for a testimonial.  Just be sure to keep to a first name basis for privacy sake, like: Sally says, “I am so happy I found Dr. Smith.  I have never felt better.”

Physician referrals and “industry” word of mouth are significant factors patients consider when selecting a provider.  Always try to cultivate good professional relationships with local hospitals and other physicians and don’t forget to “return the favor” for those who regard highly as well.

See the Medical Business Systems website for more insight on creating a successful medical practice with Iridium Suite Practice 

Do Medical Billers Make New Year's Resolutions?

As made fact by the all-knowing Google search, these are the typical top 10 New Year’s Resolutions in no particular order:

Eat Healthy/Exercise Regularly exercise improves health / Drink Less : Learn Something New continued education / Better Work/Life Balance Quit Smokingquit smokingSave Money   save money / Volunteer / Get Organized   organizational tools Read More reading Finish To-do Listto do list

So if you are sitting in your billing office, looking ahead to 2014, your list of resolutions might look similar to those below.  Iridium Suite Practice Management Software wants to help you keep your medical billing resolutions.  We offer free access to informative blog articles, user forums, healthcare infographics, white papers and ebooks.

Learn how to use ICD-10… I have until October 1! continued education. Increase revenue by analyzing fee schedules and negotiate better reimbursements. save money reading Read newsletters and healthcare articles to keep up with billing changes like new CPT codes, additional PQRS measures, claims filing rules (like the new HCFA 1500 format and quarterly CCI edits)

Organize my EDI transactions to maximize new payer ERA and EFT mandates. organizational tools to do list Keep up with those dreaded tasks like patient accounts receivables follow-up.