(Medicare Claims Processing Manual)

130.2 - Global Allowances  (Rev. 2024, Issued: 08- 06-10, Effective: 01 -01-11, Implementation: 01- 03-11)  When a certified nurse- midwife is providing most of the care to a Medicare beneficiary that is part of a global service and a physician also provides a portion of the care for this same global service, the fee paid to the CNM for his or her care is based o n the portion of the global fee that would have been paid to the physician for the care provided by the CNM.   For example, a CNM requests that the physician examine the beneficiary prior to delivery.  The CNM has furnished the ante partum care and intends to perform the delivery and post partum care.  The physician fee schedule amount for the physicians total obs tetrical care (global fee) is $1, 000.  The physician fee schedule amount for the physicians office visit is $30.  The following calculation shows the maximum allowance for the CNMs service:   Physician fee schedule amount for total obstetrical care  $1,000.00  Physician fee schedule amount for visit  - $30.00  Result  $ 970.00  Fee schedule amount for certified nurse -midwife (65% x $970, effective January 1, 1992 thru December 31, 2010.)  $ 630.50   Fee schedule amount for certified nurse -midwife (100% x 970, effective January 1, 2011.)  $970.00   Therefore, the certified nurse- midwife would be paid no more than 80 percent of $630.50, or   80 percent of $970.00 for services furnished on or after January 1, 2011, for the care of the beneficiary.   This calculation also applies when a physician provides most of the services and calls in a certified nurse- midwife to provide a portion of the care.   Physicians and certified nurse -midwives use reduced service modifiers to report that they have not provided all the services covered by the global allowance.   140 - Qualified Nonphysician Anesthetist Services  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Section 9320 of OBRA 1986 authorized payment under a fee schedule to certified registered nurse anesthetists (CRNAs) and anesthesiologists assistants. CRNAs and anesthesiologists assistants may bill Medicare directly for their services or have payment made to any individual or entity (such as a hospital, critical access hospital, physician, group practice, or ambulatory surgical center) with which the CRNA or anesthesiologists assistant has an employment or contractor relationship that provides for payme nt to be made to the individual or entity.     140.1  - Qualified Nonphysician  Anesthetists  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) For payment purposes, the term qualified nonphysician anesthetist is used to refer to both certified registered nurse anesthetists (CRNAs) and anesthesiologists assistants unless otherwise separately discussed.     An anesthesiologists assistant means a person who:    Works under the direction of an anesthesiologist;    Is in compliance with  all applicable requirements of State law, including any licensure requirements the state imposes on nonphysician anesthetists; and    Is a graduate of a medical school based anesthesiologist assistant educational program that    o Is accredited by the Committee on Allied Health Education and Accreditation;   And   o Includes approximately two years of specialized basic science and clinical education in anesthesia at a level that builds on a premedical undergraduate science background.    A CRNA is a registered nurse who:    is licensed as a registered professional nurse by the State in which the nurse practices;    Meets any licensure requirements the State imposes with respect to nonphysician anesthetists;    Has graduated from a nurse anesthesia educational program that meets the standards of the Council on Accreditation of Nurse Anesthesia Programs; and   Meets the following criteria: o Has passed a certification examination of the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists;   Or   o Is a graduate of a nurse anesthesia educational program that meets the standards of the Council of Accreditation of Nurse Anesthesia Educational Programs, and within 24 months of graduation, has passed a certification examination of the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists.    140.2  - Entity or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician  Anesthetists  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Payment for the services of a qualified nonphysician anesthetist may be made directly to the qualified nonphysician anesthetist who furnished the anesthesia services or have payment made to any individual or entity (such as a hospital, critical access hospital, physician, group practice, or ambulatory surgical center) with which the CRNA or anesthesiologists assistant has an employment or contractor relationship that provides for payment to be made to the individual or entity.    140.3  - Anesthesia Fee Schedule Payment for Qualified Nonphysician  Anesthetists (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Payment for the services furnished by qualified nonphysician anesthetists are subject to the usual Part B coinsurance and deductible, and are made only on an assignment basis. The assignment agreed to by the qualified nonphysician anesthetist is binding upon any other person or entity presenting a claim or request for payment for the service. Except for deductible and coinsurance amounts, any person who knowingly and willfully presents or causes to be presented to a Medicare beneficiary a bill or request fo r payment for services of a qualified nonphysician anesthetist for which payment may be made on an assignment -related basis is subject to civil monetary penalties.   The fee schedule for anesthesia services furnished by qualified nonphysician anesthetists is the applicable locality -adjusted anesthesia conversion factor multiplied by the sum of allowable base and time units, as defined in 50 of this chapter.   The allowance for an anesthesia service furnished by a qualified nonphysician anesthetist that meets the requirements for payment at the medically directed rate is based on a fixed percentage of the allowance recognized for the anesthesia service personall y performed by the physician alone, as specified in 50 of this chapter.    The anesthesia locality -adjusted conversion factor for anesthesia services furnished by a CRNA that does not meet the requirements for payment at the medically directed rate may not exceed the allowance for a service personally performed by a physician, as  specified in 50 of this chapter.     140.3.1 - Conversion Factors Used for Qualified Nonphysician  Anesthetists  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)  The anesthesia locality -adjusted conversion factors are updated by the update factor used to update physicians services under the physician fee schedule. They are generally published in November of the year preceding the year in which they apply.   140.3.2  - Anesthesia Time and Calculation of Anesthesia Time  Units  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Anesthesia time  means the time  during which a  qualified nonphysician anesthetist is present with the  patient.  It starts when the  qualified nonphysician anesthetist begins to prepare the  patient for  anesthesia services in the operating  room or  an equivalent area and ends when the qualified  nonphysician anesthetist is no longer furnishing anesthesia services to the patient, that is, when the patient may  be placed safely  under postoperative care.  Anesthesia time  is a continuous time period from the  start of  anesthesia to the end of an anesthesia service.  In counting anesthesia time, the  qualified nonphysician anesthetist can add blocks of time  around an interruption in anesthesia time as long as the qualified nonphysician anesthetist is furnishing continuous anesthes ia care within the  time  periods around the interruption.    140.3.3 - Billing  Modifiers (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17)  The following modifiers are used by qualified nonphysician anesthetists when billing for anesthesia services:   QX  Qualified nonphysician anesthetist service: With medical direction by a physician.  QZ  CRNA service: Without medical direction by a physician.   QS  Monitored anesthesia care services   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.  140.3.4 - General Billing Instructions  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Claims for reimbursement for qualified nonphysician anesthetist services should be completed in accordance with existing billing instructions for anesthesiologists with the following  additions.  If an employer-physician furnishes concurrent  medical  direction  for a procedure involving CRNAs  and the medical  direction  service is unassigned, the physician should bill on an assigned  basis  on a separate claim  for the qualified  nonphysician anesthetist  service.  If the physician is  participating  or takes  assignment, both services  should be billed on one claim but as separate line items.    All claims  forms  must  have the provider billing  number of the qualified nonphysician anesthetist and/or the employer of the qualified  nonphysician anesthetist  performing  the service in either  block 24.H of the Form  CMS -1500 and/or block 31 as  applicable.  Verify  that the billing  number is valid  before making payment.  Payments should be calculated in accordance with Medicare payment rules in 140.3. The A/B MAC must institute all necessary payment edits to assure that duplicate payments are not made to physicians for qualified nonphysician anesthetist services or to a qualified nonphysician anesthetist directly for bills submitted on their behalf by qualified billers.  A CRNA is identified on the provider file by specialty code 43. An anesthesiologists assistant is identified on the provider file by specialty code  32.  140.4 - Qualified Nonphysician Anesthetist Special Billing and Payment Situations  (Rev. 2716, Issued: 05- 30-13, Effective:01 -01-13, Implementation: 02- 12-13)  140.4.1 - An Anesthesiologist and Qualified Nonphysician Anesthetist Work Together  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) A/B MACs will distribute educational releases and use other established means to ensure that anesthesiologists understand the requirements for medical direction of qualified nonphysician anesthetists.  A/B MACs will perform reviews of payments for anesthesiology services to identify situations in which an excessive number of concurrent anesthesiology services may have been performed. They will use peer practice and their experience in developing review criteria. They will also periodically review a sample of claims for medical direction of four or fewer concurrent anesthesia procedures. During this process physicians may be requested to submit documentation of the names of procedures performed and the names of the anesthetists medically  directed.  Physicians who cannot supply the necessary documentation for the sample claims must submit documentation with all subsequent claims before payment will be  made.   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.