Medical Billing
For Anesthesia Care Team Cases

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. 

Insurance Payment
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

If you have further questions or would like to know more about the Anesthesia Services MSN provides, please contact one of our Client Services Team Members or call us at 1-800-889-8610. 

Hal Nelson, Vice President Anesthesiology Services


VP of Anesthesiology Services

Hal has 30+ years of experience on both the payor 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 anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.

This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document.  All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.

Latest Posts

Service Inquiry

To discover more about all MSN has to offer, complete the MSN Services Inquiry form.

Sign Up

To stay up-to-date on the latest industry news, sign up for MSN email communications.

Share this post:

Related Posts

MSN Services Inquiry

If you would like to learn more about MSN services for your practice, please call us or use the form below.

1-866-567-7405  / Local: 706-653-8150

Interested Services:

MSN Email Sign Up

Proactive communication and education are essential to running efficient and profitable practices.

Sign up below to receive regular industry news!