(Medicare Claims Processing Manual)

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.    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 anesth esia 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.