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Foundation Principals for Anesthesia Teaching Cases  

Published on August 2, 2019

The key to compliance victory and proper reimbursement of Student Registered Nurse Anesthetist and Resident cases begins with understanding some foundational medical direction principals. 

1 MD + 1 Resident case = 100% payment of allowed amount.  Physician medical direction of a resident is limited by CMS to a maximum of two residents.  The claim is billed in the physician name and with modifiers AA and GC (service performed by a resident under direction of a teaching physician). 

1 MD + 1 SRNA case = 100% payment of allowed amount.  Physician medical direction of a SRNA is limited by CMS to a maximum of two concurrent cases, however ASA suggests not exceeding 1:1 ratio with a SRNA.  The 1:1 MD/SRNA ratio is billed only in the teaching anesthesiologist name and with AA modifier. 

1 MD + 2 SRNA cases = 50% payment of allowed amount.  Should there be a 1:2 ratio then it is billed in the teaching anesthesiologist name with QK modifier.  “The requirements for payment at the medically directed rate apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologist’s assistant, intern or resident).” (CMS p.6) 

1 CRNA + 1 SRNA case = 100% payment of allowed amount.  CRNA medical direction of a SRNA, with the teaching CRNA continuously present, is billed in the CRNA name and with QZ modifier.  “Payment can be made under Part B to a teaching CRNA who supervises a single case involving a student nurse anesthetist where the CRNA is continuously present.  The CRNA reports the service using the QZ modifier.  No payment is made under Part B for the service provided by a student nurse anesthetist.” (CMS p.13)

1 CRNA + 2 SRNA in separate concurrency cases = reimbursement varies.  Medical direction of 2 SRNA’s is not as simple, nor is it practical to practice this way.  Payment may be allowed if a teaching CRNA is involved in cases with two SRNA’s but is limited to only billing for the actual time in each case, so not really billing for medical direction.  For example, to bill base units in each case, the CRNA must be present for pre-op and post-op care in each case.  Both cases would be billed QZ with only the time spent in the room on each case billed (not total anesthesia time). (CMS p.13)

Although the guidelines for billing in a teaching situation can be a bit confusing, following the proper medical direction and documentation process will pay off from both a financial and auditing standpoint. 

 

Carolyn Wilson

Patient Registration Manager

 

References:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3747CP.pdf

Section 50-C, p. 6

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3747CP.pdf

Section 140.5, p. 13