Billing As Non-Medically Directed (-QZ) For Anesthesia Care Team Cases
Billing Options For Anesthesia Care Team Cases
Anesthesia groups who employ their Certified Registered Nurse Anesthetists (CRNAs) have the option to bill their cases as medically directed or non-medically directed.
The latter may be appealing for practices that have difficulty meeting the TEFRA requirements for care team billing, specifically the anesthesiologist’s presence at induction and emergence.
This article is intended to explain the difference in both billing models, and to provide guidance to practices as they consider their options.
CMS Medical Direction Rules
The CMS Medical Direction rules came about as a result of The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Earmarked in this legislation were Medicare conditions of payment for care team anesthesia. Specifically, the new rules mandated the performance and documentation of 7 clinical activities by the Anesthesiologist, while overseeing non-physician practitioners, such as Anesthesiology Assistants (AAs) and Certified Registered Nurse Anesthetists (CRNAs).
Those requirements are as follows:
- Ensuring the anesthetist is qualified
- Participation in the pre-anesthesia assessment
- Providing frequent monitoring
- Presence at Induction and Emergence
- Remaining immediately available
- Providing post-anesthesia care, as indicated
For busy anesthetizing locations, these requirements may be difficult, if not impossible, to consistently meet.
Billing as Non-Medically Directed
Due to this fact, groups often explore the option of billing their cases as non-medically directed instead. This is done by submitting a single claim under the CRNA’s name only, with anesthesia modifier -QZ.
Billing as Medically Directed
Alternatively, medical direction claims have line-item charges for both the anesthesiologist and the CRNA, using modifiers -QK and -QX respectively.
NOT “All or Nothing”
It’s doesn’t have to be an “all or nothing” decision – practices can designate specific anesthetizing locations within a facility as “collaborative” (aka non-medically directed), such as GI or Eyes. In this instance, anesthesia personnel would be dedicated to the specific perioperative site and not involved with the other concurrent OR cases.
From an insurance payment standpoint, both billing models are typically paid at the exact same rate. That’s not to say that some insurance plans have a reduced fee for -QZ billing, but they’re the exception and not the norm.
Groups considering this option should look at their top payer policies to confirm the budget neutrality of switching to this billing model.
If your payer mix allows, it provides immediate clinical relief for anesthesiologists who are asked to be physically present a minimum of 8 times during a 4-room concurrency. It also mitigates billing compliance risk, since the medical direction rules no longer apply.
An Attractive Option
For these reasons, non-medical direction has become an attractive option to groups working in busy anesthesia practices, where their staff is stretched thin. It should be noted that this billing model doesn’t work for Anesthesiology Assistants, who have to be medically directed, per CMS. It also doesn’t work for Residents or Student Registered Nurse Anesthetists, who have their own unique payment policies.
However, it does work perfectly for CRNAs. Some pundits say that this billing model skews claims’ data to look like more independent CRNA services are being provided, thus helping AANA lobbying efforts.
Although I’ll steer clear of this topic, we will say claims data alone is not representative of the clinical services provided – that’s what the anesthesia record is for.
This is simply a billing option, for groups trying their best to balance compliance obligations with daily clinical demands. Ultimately, each anesthesia group will decide what works best for their individual practice.
MSN Healthcare Solutions
Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.
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