Keep It Together When Coding Incomplete Medical Direction

Anesthesia & Pain Management Coding Alert 2008: Volume 10, Number 5

Look before you leap into using these tricky modifiers

In anesthesia cases in which medical direction is incomplete, you may be considering creating a claim in the CRNA’s name, appended with modifier QZ. Before you do that, there are a few things you need to keep in mind.

You Carrier Is the Best Place to Start

You need to be aware that there isn’t now a policy for incomplete medical direction at the national level. “Reimbursement for these cases is determined by the local carrier -- it can vary from case to case,” says Cindy Lane, CPC, CHCC, with Advanced Coding Solutions in Whitehouse, Tenn.

But, in general, the CRNA could submit the claim by using modifier QZ (CRNA service: without medical direction by a physician), or the physician might report the procedure using modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures).

Be careful: If the physician reports modifier AD, the correct corresponding CRNA modifier is QX (CRNA service: with medical direction by a physician). Reporting modifier QZ will pay 100 percent of the CRNA’s services in addition to the physician reimbursement.

Smart move: You want to be clear about who employs the CRNA to make sure that the proper entity is filing the claim. If the group employs the CRNA, it may file the CRNA services with its services (just keep in mind that the group doesn’t necessarily need to report these modifiers). If the group doesn’t employ the CRNA, the payer usually pays the first claim filed and rejects the second claim.

Play it safe: Checking with your carriers to make sure that they recognize all of the HCPCS modifiers you plan to use in your claim is always a good idea. Your reporting method may depend on the exact circumstances that rendered medical direction incomplete.

Save Yourself a Headache, Explain Circumstances

By submitting a claim clearly indicating the portion of the case that met medical direction -- as well as the portion that didn’t -- your local carrier can make a decision based on the circumstances for your specific claim. In some cases, carriers will still allow reimbursement for the entire claim based on medical direction.

Regardless of the appropriate reporting method for your case, always remember that the physician’s time involved has to be considered when reporting concurrent cases.

“By eliminating the physician from the claims process -- submitting the CRNA with a QZ modifier, for example -- you still have to consider the physician’s time involved when determining the appropriate modifier for the cases that were running concurrently,” Lane says.

Learn One Last Piece of Compliance Wisdom

You need to be familiar with the seven steps of medical direction and the exceptions that Medicare allows. Certain services can be performed without interrupting medical direction. Know those services -- and make absolutely sure that your attending physician hasn’t met the requirements before you start to alter your claims.