1. What guideline should a provider use to determine whether a specific service can or cannot be provided at the same time as medical direction?
A physician who is providing medical direction of anesthesia care cannot ordinarily provide additional services to other patients. If the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature, and therefore, are not paid under the fee schedule.
2. May an anesthesiologist perform preoperative evaluations for patients presenting for surgery later that day, or on future days?
Yes. As long as:
The area evaluations are performed, is easily accessible from any area of the operating suite;
The patient services do not prevent the physician from being immediately available to address emergencies in the operating room;
And most importantly “do not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to surgical patients.”
3. May an anesthesiologist perform procedures either on patients presenting for surgery that day, preoperatively or in the post-anesthesia care unit?
An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions, central venous catheter insertions, pulmonary artery catheter insertions, and epidural, spinal, and peripheral nerve blocks) performed in an area immediately available to the operating room when performance of such services does not prevent him/her from being immediately available to respond to the needs of surgical patients.
4. What constitutes the “immediate area of the operating suite”?
Differences in the geographic design and size of facilities, differences in the severity of illness, and the complexity and demands of the particular surgical procedures make this distance impossible to define. That said, the anesthesiologist must remain close enough to the operating room to return to the operating room, if/when needed, in time to meet the needs of the patient, and most importantly, emergencies that may arise.
5. In the event that an anesthesiologist is medically directing one to four concurrent cases, but due to some intervening factors, is unable to be present at emergence; is not immediately available for some portion of the case; or fails to note periodic monitoring on the chart, is it permissible to bill the case with modifier "QZ" (CRNA service; without medical direction by a physician) as if the services were provided by a non-medically directed Certified Registered Nurse Anesthetist (CRNA)?
If the medically directing anesthesiologist meets the requirements for medical direction of anesthesia services, the anesthesiologist reports modifier QK; the CRNA reports modifier QX.
If the medically directing anesthesiologist does not meet the requirements for medical direction of anesthesia services, the CRNA reports modifier QZ; the anesthesiologist does not bill the service at all.
The medical documentation must support the level of medical direction provided as well as the modifier reported for the anesthesia service.
Medically directed anesthesia modifiers:
QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QX – Qualified nonphysician anesthetist service: With medical direction by a physician.
QZ – CRNA service: Without medical direction by a physician.
6. Do you agree that there is no definable period of induction or emergence for Monitored Anesthesia Care (MAC), and therefore, the medically directing anesthesiologist need not indicate presence for induction and emergence for these cases?
According to the CMS manual and our Local Coverage Determination (LCD), close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.
The CMS requirements for MAC should be the same as general anesthesia with regards to:
The performance of pre-anesthetic examination and evaluation.
The prescription of the anesthesia care required.
The completion of an anesthesia record.
The administration of necessary medications and the provision of indicated postoperative anesthesia care.
Appropriate documentation must be available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.
Since 'induction' or 'emergence' is not listed above, we would not expect to see these terms in the medical record.
7. May a medically directing anesthesiologist take a short break to eat a meal or use the rest room? What is a reasonable length of break time that a CRNA can provide to a physician who is personally administering a case without it being 'medically directed'? In a group practice, may the group bill for medical direction when the medically directing anesthesiologist is unable to be present for a key portion of a case, but another anesthesiologist within the group is present for the key portion of the case?
The above questions pertain to the care and safety of the patient. It is the responsibility of the hospital to ensure the anesthesia service is organized and staffed in such a manner as to ensure the health and safety of patients.
Addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, periodic (rather than continuous) monitoring of an obstetrical patient, receiving patients entering the operating suite for the next surgery, checking or discharging patients in the recovery room, or handling scheduling matters, do not substantially diminish the scope of control exercised by the physician and do not constitute a separate service for the purpose of determining whether the requirements for payment at the medically directed rate are met.
However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature, and therefore, are not paid under the fee schedule.
If anesthesiologists are in a group practice, one physician member may provide the pre- anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.
8. How do I bill anesthesia spanning multiple days?
Anesthesia is billed using the date anesthesia time begins for the patient with units reflecting total anesthesia time in minutes. The “to date” does not come into play with anesthesia billing/services nor payment of those services; it is based on the collective time billed for the service.
9. Does Medicare pay for multiple anesthesia services on the same day?
Yes, payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral procedures.
For anesthesia services associated with multiple bilateral surgeries, report the anesthesia procedure with the highest base unit value with the multiple procedure modifier -51. And, report the total time for all procedures in the line item with the highest base unit value.
If the same anesthesia code applies to two or more surgical procedures, enter the anesthesia code with the -51 modifier and the number of surgeries to which the modified CPT code applies.
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures.