Medicare Increases Scrutiny of Anesthesia Billing

Medicare is increasing its scrutiny of anesthesia billing as a result of recovery auditors finding a high percentage of errors involving the incorrect use of the HCPCS modifiers for anesthesia. These errors are specifically associated with situations when anesthesia was provided by a CRNA and anesthesiologist without a 50% reduction as per Medicare guidelines involving CRNAs supervised by anesthesiologists.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, auditors determined that when anesthesiologists append modifiers -QY, -QK, or -AD, they are stating the procedure was supervised, and accept 50% of the fee schedule payment. When the CRNA states, through the use of the -QZ modifier, that the same procedure was not supervised and accepts 100% of the fee schedule, an overpayment to the CRNA exists.

Here are two scenarios CMS provided to illustrate overpayment scenarios:

Example: The CRNA billed HCPCS code 00142 (Anesthesia for procedures on eye; lens surgery) with modifier -QZ (CRNA service: without medical direction by a physician) for date of service of May 18, 2010. However, for the same beneficiary, the same procedure code and date of service, the anesthesiologist billed with a -QK modifier (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), triggering an overpayment.

Example: The CRNA billed HCPCS code 01215 (Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty) with modifier -QZ (CRNA service: without medical direction by a physician) for date of service August 1, 2011. For the same beneficiary, procedure code and date of service, the anesthesiologist also submitted a claim with a -QY modifier (Medical direction of one CRNA by an anesthesiologist), triggering an overpayment.

How to Avoid These Problems

When submitting bills in instances where the anesthesiologist supervises a case and the CRNA provides the anesthesia services, CMS notes that their total compensation should not exceed 100% of the highest fee schedule of the anesthesiologist or CRNA.

Therefore, when anesthesiologists append modifiers -QY, -QK or -AD, they are stating the procedure was supervised, and accept 50% of their fee schedule payment.

The CRNA must be careful when stating, through the use of the -QZ modifier, that the procedure was truly not supervised. If the CRNA is supervised and accepts 100% of the fee schedule, an overpayment to the CRNA exists.

If you are struggling to properly bill for anesthesia services, consider outsourcing your medical billing for anesthesiologists and CRNAs to one of the nation's leading anesthesiology billing vendors: PGM Billing. PGM has more than 30 years of coding and billing experience, with a team of certified, expert billers dedicated to anesthesia billing. PGM will help ensure you receive the correct reimbursement for the anesthesia services you deliver while avoiding improper billing that could bring increased scrutiny from the federal government upon your organization.


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