Anesthesia reimbursement comes with unique challenges, as experienced medical billing and coding companies know. A recent Department of Veteran Affairs (VA) ruling puts the spotlight on the providers of anesthesia services and can also affect CRNA medical billing.
Anesthesiologists and Certified Registered Nurse Anesthetists (CRNA) face medical billing issues related to cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times. Anesthesiologists have to adhere to stringent federal guidelines and watch out for even minor errors documentation errors which can lead to overbilling. ICD-10 has brought about many changes for the anesthesiology specialty and specificity in clinical documentation is the key to proper coding for maximum reimbursement. Payment also depends on the correct use of modifiers.
There are specific rules for CRNA medical billing based on the setting in which services are provided. The anesthesia modifier on the CRNA claim informs the insurance company that the CRNA was medically directed. CRNAs can bill the Medicare program either:
- Directly for services using their National Provider Identifier (NPI) or
- Under the NPI of a hospital, physician, group practice, or ASC with which they are employed in or contracted
Time and modifiers are crucial components in anesthesia medical billing and coding. Anesthesia time is the continuous period that begins when the patient is prepared for anesthesia services in the operating room or equivalent area and ends when the patient may be placed safely under postoperative care. Time blocks can be included around an interruption in anesthesia time as long as continuous anesthesia care is furnished within the time periods around the break.
Anesthesia billing modifiers include:
- QS – Monitored anesthesia care service
- QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist
- QZ – CRNA service: without medical direction by a physician
- QX – CRNA service: with medical direction by a physician
Failing to document relief times could cause a compliance problem. Anesthesiologists cannot relieve Certified Registered Nurse Anesthetists (CRNAs) that they are medically directing. Best practices require that the CRNA has to relieve a CRNA and an MD has to relieve an MD.
MedPage reported on the VA’s new rule which states that the CRNAs will not be able to independently administer anesthesia. However, the VA’s amended medical regulations permit full practice authority of three roles of VA advanced practice registered nurses (APRN) – certified nurse-midwives, nurse practitioners, and clinical nurse specialists – when they are acting within the scope of their VA employment. These APRNs will be able to practice “without the clinical supervision or mandatory collaboration of physicians.”
Certified registered nurse anesthetists are a vital component in the US healthcare system. In addition to the healthcare facilities of the military, public health services and Department of Veteran Affairs, CRNAs deliver anesthesia care in traditional hospital surgical suites, obstetrical delivery rooms, critical access hospitals, ambulatory surgical centers, and the offices of dentists, podiatrists, plastic surgeons and pain management specialists.
Leaving CRNAs out of the new VA policy has come in for much debate. The American Medical Association’s Board of trustees has expressed disappointment with the proposal and urged the VA to maintain the physician-led model within the healthcare system to ensure coordination of care for veterans. The AMA says that administration of anesthesia requires physician leadership for patient safety and does not support the ruling that the other advanced nurse categories will be able to practice independently.
The American Society of Anesthesiology (ASA) has supported the decision to withhold full authority from the CRNAs on the grounds that veterans have multiple medical conditions that increase risk of complications during and after surgery and anesthesia. The ASA, however, commends the role of CRNAs in the operating room.
The American Association of Nurse Anesthetists (AANA) is understandably disappointed with the new VA rule and recommends that all advance practice nurses, including CRNAs, be granted full practice authority.
MedPage reports that the AANA president said, “We, as advance practice registered nurses (APRNs), all realize we’re ready and capable [of providing] the services that are necessary for our veterans today.”