Anesthesia: Troubleshoot Your Medical Direction/Supervision Confusions

Modifiers that indicate whether the anesthesiologist supervised or directed are QY, QK, and AD.

Do you sometimes find yourself in a fix whether you should report an anesthesiologist’s case as medically directed or medically supervised? You’re not alone.   Even the most experienced coders get caught in the medical direction vs medical supervision confusion. Here are some basics about medical direction/supervision with a common scenario to help you handle such confusions better:

Categorize Correct Direction/Supervision

The first thing you need to do is verify the number of concurrent cases the anesthesiologist was involved in at the time. The modifiers that point to whether the anesthesiologist supervised or directed are:

·         QY – Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

·         QK – Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

·         AD – Medical supervision by a physician; more than 4 concurrent anesthesia procedures.

                                              

Points to note: Concurrent anesthesia procedures are those that overlap – that could mean even by a minute. The anesthesiologist moves from medical direction to medical supervision after he oversees more than four concurrent anesthesia procedures. Medical supervision also applies if the anesthesiologist does not meet all seven criteria for medical direction.

 

Payments for medical direction:

If the anesthesiologist meets all criteria for providing medical direction, each procedure he directs reimburses 100 percent. (This is split 50/50 between the physician and CRNA).

Payments for medical supervision:

Payment for medical supervision is based on three units. (in addition to one more unit if the anesthesiologist took part in induction) for the physician and 50 percent payment for CRNA.

Heed this advice: Instead of taking it up yourself, let the payer adjust the number of units. Check your guidelines for specific instructions and be prepared that Medicare will reduce the units for you whenever it feels is applicable. Include the appropriate modifier for the physician’s medical direction or supervision on each claim the anesthesiologist files. Additionally, you could consider investing in an SuperCoder Anesthesiacoding resource to help you overcome difficult anesthesia coding scenarios with guidance on medically directed vs medically supervision confusions, qualifying circumstances codes, anesthesia modifiers, base units, 2014 performance measurement codes, post-op blocks, and more.

Here’s a scenario to further help your understanding of medical direction/supervision:

In an office setting, your providers offer kyphoplasty. The physician performs the kyphoplasty and the CRNA administers anesthesia.

How to code this?

The anesthesiologist will report the correct procedure code(s) for the kyphoplasty (22523-+22525) while the CRNA will report the anesthesia with 01936 (Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic). Do not report a medical direction/supervision modifier for the anesthesiologist since a physician cannot personally perform a procedure while medically directing or supervising a CRNA.

But note: You should add modifier QZ to the CRNA’s claim.

CCI 20.1: When to Report Chemodenervation Procedures Over Other Services

Do you code for chemodenervation procedures? If yes, you will need to read the latest Correct Coding Initiative Edits (CCI 20.1) very carefully.

In the last few years, chemodenervation coding has undergone multiple changes – including adding 64616 this year. And this time you will find more CCI edits that feature chemodenervation services. The latest CCI edits that went into effect on April 1 confirms when you should report these chemodenervation procedures over other services. 

Which Chemodenervation Code Overrides Other Pairs in CCI 20.1

Sometimes a provider will perform chemodenervation to multiple anatomic sites during the same encounter. In such scenarios, you should report 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine]) or 64616 when paired with many other chemodenervation services, according to the latest CCI edits. These include: 64642, +64643, 64644, +64645, and 64646.

There are exceptions: The significance of the codes 64615 changes when performed during the same encounter as 64617. In such scenarios, you use code 64617 as the codeable service in place of 64615.

Needle EMG with Chemodenervation is a Strict No

Normally an anesthesia provider would rarely conduct a needle EMG. But in case he does, CCI clarifies that the EEG is secondary to anesthesia. What you can do:  Report chemodenervation code 64616 instead of needle EMG codes 95860-95870. 

Modifier indicator: The code pair of 64615 and 64616 has a modifier indicator of “0”. This means you cannot add a modifier and unbundle the codes to report both services. All the other edits in the latest CCI 20.1 related to chemodenervation procedures are classified with modifier indicator “1”, meaning you may be able to add a modifier to the second code of the pair and report both services. But see to it that you have adequate documentation supporting how the procedures are separate before submitting both codes.

Resource: Check the complete CCI file on the CMS website to see which edits apply to your practice or sign up for a monthly anesthesia coding newsletter to get complete CCI coverage like which chemodenervation code overrides others when paired together along with  all the specialty-specific coding  and reimbursement guidance you need to avoid costly denials and garner maximum pay.  

Anesthesia Coding: Clear Your Medical Direction vs. Medical Supervision Confusion

Include the applicable modifier for the physician’s medical direction or supervision on each claim!

Confused whether you should report an anesthesiologist’s case as medically directed or medically supervised?  You’re not alone; even the most experienced coders struggle with this. Not knowing this can make or mar your practice’s bottom-line.  

Here are some basics about medical direction vs. medical supervision that will help you handle the situation:

Classify Direction/Supervision Correctly

Verify the number of concurrent cases the anesthesiologist was involved in at the time.  The modifiers that designate whether the anesthesiologist supervised or directed are:

·         QY – Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

·         QK – Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

AD – Medical supervision by a physician; more than 4 concurrent anesthesia procedures

Important: Concurrent anesthesia procedures are those that overlap – even if only by a minute. Once the anesthesiologist oversees more than four concurrent anesthesia procedures, he shifts from medical direction to medical supervision. Medical supervision also applies if the anesthesiologist doesn’t meet all seven criteria for medical direction. 

Payment Info

If the anesthesiologist meets all criteria for providing medical direction, each procedure he directs pays 100 percent (which is split 50/50 between the physician and CRNA). For medical supervision, payment is usually based on three units (including one additional unit if the anesthesiologist took part in induction) for the physician and 50 percent for the CNRA.

Here’s what you can do: Instead of doing it yourself, let the payer adjust the number of units for the anesthesiologist. Make sure you check your local guidelines for specific instructions and know that Medicare will reduce the units when appropriate. Add the correct modifier for the physician’s medical direction or supervision on each claim the anesthesiologist files.

Get more anesthesia coding and reimbursement guidance to ensure optimal payments in SuperCoder Anesthesia Coding Alert. 

Selective Catheter Placement with Vessel Repair

Plus, don't mix new compression codes with manipulation.

Certain CPT® codes 2012 that sidestepped Correct Coding Initiative (CCI) edit pairs in January are all bundled up as of April 1, 2012. That implies that you'll be required using caution while billing certain vascular injection and blood vessel repair codes together. Read on to learn other changes that general surgery coders need to know.

Avoid 36251 with 35231 and Beyond

CCI 18.1 adds almost 50 edit pairs with the following listed blood vessel repair CPT® codes 2012 in the column 2 position:

    35231 -- (Repair blood vessel with vein graft; neck)

    35236 -- (upper extremity)

    35256 -- (lower extremity)

    35261 -- (Repair blood vessel with graft other than vein; neck)

    35266 -(upper extremity)

    35286 --(lower extremity)

Based on "CPT Manual or CMS manual coding instructions," as per the CCI edit table, you shouldn't report the preceding codes with the following new CPT® codes 2012 for the same vessel:

    36251-36254 - (Selective/superselective catheter placement %u2026)

    37191-37193 - (Insertion/repositioning/retrieval of intravascular vena cava filter %u2026)

Nix Compression With Manipulation

CPT® 2012 added three novel multi-layer compression system ul

li29582 -- (Application of multi-layer compression system; thigh and leg, including ankle and foot, when performed)

li29583 -- (Application of multi-layer compression system; upper arm and forearm)

li29584 -- (Application of multi-layer compression system; upper arm, forearm, hand, and fingers)

/ul

bLook for Streamlined Edit Groupings /b br

There's a twist in the way this newest round of edits is organized that could make things stress-free for you. br

bThat was then: /b Since 1996, CMS has allocated procedure-to-procedure CCI Edits either to the Column One/Column Two Correct Coding edit file or the Mutually Exclusive edit file based on the condition for each edit. The Mutually Exclusive edit file covered edits including two procedures that could not be executed at the same patient encounter as they were mutually exclusive based on anatomic, temporal, or gender considerations. CMS then assigned all other edits to the Column One/Column Two Correct Coding edit file.

This is now: With the April 2012 release, CMS combines the two edit files into the Column One/Column Two Correct Coding edit file. CMS executed the consolidation both for the Physician CCI edit files and the Hospital (also known as theOutpatient Code Editor or OCE) edit files. The change should definitely make it easier for users, as now you'll only have to search the Column One/Column Two edit file for active or formerly deleted edits.

Medicare Physician Fee Schedule: Get Ready For ED E/M Coding Adjustments, Telehealth Coverage

Watch for these RVU changes to determine your 2012 payments

In case you were hoping for a reprieve in 2012 from the recession cost stresses on EDs, the word is that you can anticipate an overall decrease of 1.5 percent in entire 2012 CMS payments. Read this expert medical coding insight and learn how this all breaks down and will influence your ED billing.

2012 Medicare Physician Fee Schedule facts: The Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule Final Rule Nov. 1, 2011, which addresses changes to the physician fee schedule, as well as other significant Medicare Part B payment policies. The rule is effective beginning Jan. 1, 2012 and was published in the Nov. 28, 2011 Federal Register.

Look For Small ED E/M RVUs Decreases

As per the Medicare Physician Fee Schedule 2012 final rule, emergency medicine will involve a -1 percent update to complete RVU values in 2012. This is free of any change to the conversion factor.

The RVUs for ED E/M codes, the governing factor in defining ED reimbursement, have only second decimal point adjustments predominantly due to minor changes in practice expense. Of note, the work RVUs have not changed for 2012 and remain steady at 2011 levels.

See the chart below to compare the precise RVU E/M code breakdown for 2011 and 2012:

Anticipate More Pay for Initial, Subsequent Observation

The good news is that you can look for large RVU gains for initial and subsequent observation care services, whereas the same day observation admit and discharge codes will remain close to the 2011 values.

Prep for Pay Upticks for These ED Procedures

The 2012 RVUs allocated to complex abscess drainage 10061 (Incision and drainage of abscess [e.g. carbuncle, suppurative hidradentits , cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) will increase by almost 9 percent and the CPR code 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest] will experience a 5 percent increase. The intermediate laceration codes had diverse results. Some of the code work RVUs were reduced marginally and a few of the intermediate code values were augmented.

Medicare Physician Fee Schedule 2102 Update: Telehealth Coverage For ED Services Gets Green Light

And more good news for EDs offering telehealth services: CMS has expanded its telehealth site promotion to cover EDs, which means EDs are now qualified site for telehealth coverage. The ED was not considered a qualified site of services previously, but for 2012, Medicare is creating novel code descriptors for the telehealth codes. The definition is now being expanded beyond inpatients and includes the emergency department.

The 2012 ED telehealth codes, descriptors, and assigned RVUs are listed below. The originating site's reimbursement has been increased as well by 0.6 percent.