To accurately get reimbursed for anesthesia services, one should know billing rules and guidelines that are specific to anesthesia care. Modifiers play a crucial role in anesthesia billing due to a variety of scenarios including an anesthesiologist, nurse anesthetist, or anesthesiologist assistant. The formula used to determine payment for anesthesia services is unique to anesthesia billing only. In this article, we explained anesthesia modifiers, their descriptions, and when and how to use them.
Defining Concurrent Cases
As per the Medicare claims processing manual, ‘A physician who is concurrently furnishing services that meet the requirement for payment at the medically directed rate cannot ordinarily be involved in furnishing additional services to other patients. However, 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 discharging the patient in the recovery room, or handling scheduling matters, do not substantially diminish the scope of control exercised by the physician and do not constitute a separate service for the purpose of determining whether the requirements for payment at the medically directed rate are met.’
Note that when counting concurrent cases, all cases matter. There cannot be even one minute of overlap among any of the cases. Concurrency counts are not limited only to those cases that involve Medicare beneficiaries. There are limits on the activities an anesthesiologist may perform while providing medical direction. These are interruptible and allow the anesthesiologist to maintain the necessary level of involvement in the medically directed cases to be available for immediate diagnosis and treatment of emergencies.
Anesthesia Modifiers
Modifier AA: Anesthesia Services Performed Personally by the Anesthesiologist
Report anesthesia services personally performed by the anesthesiologist with modifier AA. Modifier AA is used when a physician anesthesiologist performs the entire anesthesia service. Or he is continuously involved in a single case with a student nurse anesthetist. Or he is involved in training residents in up to two concurrent cases meeting teaching physician requirements (while billing uses both modifier AA and modifier GC). These services have been performed by a resident under the direction of a teaching physician. Modifier AA may also apply in extraordinary circumstances in which the services of two anesthesiologists, or an anesthesiologist and a nurse anesthetist or anesthesiologist assistant are medically necessary. Medicare (and most commercial payers) pays 100 percent of the allowed amount to the physician anesthesiologist when reporting a claim with the AA modifier.
Modifier AA may only be reported by the teaching physician if the resident performs the entire case. If the resident performs a specific portion of the case (e.g. intubation, induction, placement of epidural, nerve block, etc.) and then hands off the case to a Certified Registered Nurse Anesthetist (CRNA) or other provider who completes the case, the service was no longer personally performed by the resident and teaching physician. Instead, the lower anesthesia payment modifier should be selected.
Modifier AD: Medical Supervision by a Physician for More than 4 Concurrent Anesthesia Procedures
Modifier AD is used when medical supervision is done by the anesthesiologist who is involved in more than four concurrent anesthesia services, or he performs other services while directing anesthesia care. Payment to the anesthesiologist will be based on three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedure. An additional time unit can be recognized if the physician can document he was present at induction.
Modifier QK: Medical Direction of two (2), three (3), or four (4) Concurrent Anesthesia Procedures involving Qualified Individuals
When two (2), three (3), or four (4) concurrent anesthesia procedures are medically directed, report with modifier QK. Services submitted with modifier QK will be reimbursed at 50 percent of the applicable fee schedule rate. Services by the teaching physician must be submitted with modifier QK when directing three, or four residents, student nurse anesthetists, or CRNAs concurrently.
Modifier QY: Medical Direction of one (1) Qualified Non-Physician Anesthetist by an Anesthesiologist
As the description suggests, modifier QY is used when a medical direction of one (1) qualified non-physician anesthetist is done by an anesthesiologist. In such cases, the Centers for Medicare & Medicaid Services (CMS) mentioned a few guidelines for medically directing anesthesiologists. Medicare and most commercial payers follow these guidelines. As per CMS guidelines, a medically directing anesthesiologist must:
- Perform a pre-anesthetic examination and evaluation
- Prescribe the anesthesia plan
- Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence
- Ensure that any procedures in the anesthesia plan that he/she does not perform are performed by a qualified individual
- Monitor the course of anesthesia at frequent intervals
- Remain physically present and available for immediate diagnosis and treatment of emergencies
- Provide indicated post-anesthesia care.
Modifier QX: Qualified Non-Physician Anesthetist Service (with Medical Direction by a Physician)
Modifier QX is used by a nurse anesthetist or anesthesiologist assistant when medically directed by a physician anesthesiologist. In such a case, as discussed above, a physician anesthesiologist would submit a corresponding claim for medical direction, either with modifier QK or modifier QY. Payment for this service is split between the two anesthesia professionals with 50 percent of the allowed amount paid to the anesthesiologist and 50 percent to the nurse anesthetist or anesthesiologist assistant. To cross-check check billing accuracy of anesthesia services, a claim submitted with the modifier QX should match a claim submitted with the modifier AD.
Modifier QZ: Certified Registered Nurse Anesthetist (CRNA) Service (without Medical Direction by a Physician)
This modifier is specific to certified registered 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 percent of the allowed amount for cases reported with the QZ modifier.
Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various medical billing specialties. We hope that our article on anesthesia modifiers will guide you in accurately billing for anesthesia services. If you are seeking assistance in anesthesiology billing and coding for your practice, contact us at info@medisysdata.com / 888-720-8884
Reference: Modifiers AA, AD, GC, QK, QX, QY, QZ – Anesthesia Payment Modifiers by Moda Health
