(Medicare Claims Processing Manual)

140.4.2 - Qualified Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Where a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed qualified nonphysician anesthetist, the payment amount for the service of each is 50 percent of the allowance otherwise recogn ized had the service been furnished by the anesthesiologist alone.  For the single medically directed service, the physician will use the QY modifier  and the qualified nonphysician anesthetist will use the QX modifier.    In unusual circumstances when it is medically necessary for both the CRNA  and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report using the AA modifier and the CRNA  would report using the QZ modifier.  Documentation must be submitted by each provider to support payment of the full  fee.  140.4.3 - Payment for Medical or Surgical Services Furnished by CRNAs (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Payment shall be made for reasonable and necessary medical or surgical services furnished by CRNAs if they are legally authorized to perform these services in the State in which the services are furnished. Payment is determined under the physician fee schedule on the basis of the national physician fee schedule conversion factor, the geographic adjustment factor, and the resource -based relative value units for the medical or surgical  service.    140.5 - Payment for Anesthesia Services Furnished by a Teaching CRNA  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) 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 servi ce provided by a student nurse  anesthetist.   The A/B MAC may allow payment, as follows, if a teaching CRNA is involved in cases with two student nurse anesthetists:   Recognize the full base units (assigned to the anesthesia code) where the teaching CRNA is present with the student nurse anesthetist throughout pre and post anesthesia care;  and   Recognize the actual time the teaching CRNA is personally present with the student nurse anesthetist.  Anesthesia time may be discontinuous. For example, a teaching CRNA is involved in two concurrent cases with student nurse anesthetists. Case 1 runs from 9:00 a.m. to 11:00 a.m. and case 2 runs from 9:45a.m. to 11:30 a.m. The teaching CRNA is present in case 1 from 9:00 a.m. to 9:30 a.m. and from 10:15 a.m. to 10:30 a.m. From 9:45 a.m. to 10:14 a.m. and from 10:31 a.m. to 11:30 a.m., the CRNA is present in case 2. The CRNA may report 45 minutes of anesthesia time for case 1 (i.e., 3 time units) and 88 minutes (i.e., 5.9 units) of anesthesia time for case  2.  The teaching CRNA must document his/her involvement in cases with student nurse anesthetists. The documentation must be sufficient to support the payment of the fee and available for review upon request.   The teaching CRNA (not under the medical direction of a physician), can be paid for his or her involvement in each of two concurrent cases with student nurse anesthetists; allow payment at the regular fee schedule rate. The teaching CRNA reports the anesthesia service using the QZ  modifier.   To bill the anesthesia base units, the teaching CRNA must be present with the student nurse anesthetist during pre and post anesthesia care for each of the two cases.  To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient c are in the two cases based on the complexity of the anesthesia cases, the experience and skills of the student nurse anesthetists, and the patients health status and other factors.  The teaching CRNA must document his or her involvement in the cases with the student nurse anesthetists.   150 - Clinical Social Worker (CSW) Services (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  See Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  Assignment of benefits is required.  Payment is at 75 percent of the physician fee schedule.  CSWs are identified on the provider file by specialty code 80 and provider type 56.  Medicare applies the outpatient mental health limitation to all covered therapeutic services furnished by qualified CSWs.  Refer to 210, below, for a discussion of the outpatient mental health limitation.   160 - Independent Psychologist Services  (Rev. 1, 10-01-03) B3-2150, B3-2070.2  See the Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  There are a number of types of psychologists.  Educational psychologists engage in identifying and treating education-related issues.  In contrast, counseling psychologists provide services that include a broader realm including phobias, familial issues, e tc.  Psychometrists are psychologists who have been trained to administer and interpret tests.  However, clinical psychologists are defined as a provider of diagnostic and therapeutic services.  Because of the differences in services provided, services pro vided by psychologists who do not provide clinical services are subject to different billing guidelines.  One service often provided by nonclinical psychologist is diagnostic testing.  NOTE: Diagnostic psychological testing services performed by persons who meet these requirements are covered as other diagnostic tests.  When, however, the psychologist is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the diagnostic services.   Expenses for such testing are not subject to the payment limitation on treatment for mental, psychoneurotic, and personality disorders.  Independent psychologists are not required by law to accept assignment when performing psychological tests.  However, regardless of whether the psychologist accepts assignment, he or she must report on the claim form the name and address of the physician who ordered the test.  160.1 - Payment  (Rev. 1, 10-01-03)  Diagnostic testing services are not subject to the outpatient mental health limitation.  Refer to 210, below, for a discussion of the outpatient mental health limitation. The diagnostic testing services performed by a psychologist (who is not a clinical psychologist) practicing independently of an institution, agency, or physicians office are covered as other diagnostic tests if a physician orders such testing.  Medicare covers this type of testing as an outpatient service if furnished by any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where he or she is furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist.  (It is CMS understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not.  Examples of psychologists, other than clinical psychologists, whose services are covered under this provision include, but are not limited to, educational psychologists and counseling psychologists.)  To determine whether the diagnostic psychological testing services of a particular independent psychologist are covered under Part B in States which have statutory licensure or certification, A/B MACs (B) must secure from the appropriate State agency a current listing of psychologists holding the required credentials.  In States or territories which lack statutory licensing and certification, A/B MACs (B) must check individual qualifications as claims are submitted.  Possible reference sources are the national directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board-certified, and records and directories of the State or territorial psychologica l association.  If qualification is dependent on a doctoral degree from a currently accredited program, A/B MACs (B) must verify the date of accreditation of the school involved, since such accreditation is not retroactive.  If the reference sources listed  above do not provide enough information (e.g., the psychologist is not a member of the association), A/B MACs (B) must contact the psychologist personally for the required information.  A/B MACs (B) may wish to maintain a continuing list of psychologists whose qualifications have been verified.   Medicare excludes expenses for diagnostic testing from the payment limitation on treatment for mental/psychoneurotic/personality disorders.  A/B MACs (B)  must identify the independent psychologists choice whether or not to accept assignment when performing psychological tests.  A/B MACs (B) must accept an independent psychologist claim only if the psychologist reports the name/UPIN of the physician who ordered a test.  A/B MACs (B) pay nonparticipating independent psychologists at 95 percent of the physician fee schedule allowed amount.  A/B MACs (B) pay participating independent psychologists at 100 percent of the physician fee schedule allowed amount.  Independent psychologists are identified on the provider file by specialty code 62 and provider type 35.  170 - Clinical Psychologist Services (Rev. 1, 10-01-03) B3-2150  See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.   Direct payment may be made under Part B for professional services.  However, services furnished incident to the professional services of CPs to hospital patients remain bundled.  Therefore, payment must continue to be made to the hospital (by the A/B MAC ( A)) for such incident to services.  170.1 - Payment  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health treatment limitation (the limitation).  Generally, the limitation does not apply to diagnostic services.  Refer to 210 below for a discussion of the outpatient mental health treatment limitation.