CRNA Chronic Pain

 

12.4.4 – Certified Registered Nurse Anesthetists (CRNAs)

(Rev. 295; Issued: 06-26-09; Effective/Implementation Date: 07-27-09)

Per 42 CFR 410.69(b), a certified registered nurse anesthetist means a registered nurse who:

(1) Is licensed as a registered professional nurse by the State in which the nurse practices;

(2) Meets any licensure requirements the State imposes with respect to non-physician anesthetists;

(3) Has graduated from a nurse anesthesia educational program that meets the standards of the Council on Accreditation of Nurse Anesthesia Programs, or such other accreditation organization as may be designated by the Secretary; and

(4) Meets the following criteria:

(i) Has passed a certification examination of the Council on Certification of Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or any other certification organization that may be designated by the Secretary; or

(ii) Is a graduate of a program described in paragraph (3) and within 24 months after that graduation meets the requirements of paragraph (4)(i).

For more information on CRNAs, refer to:

• Section 1861(bb) of the Social Security Act;
• 42 CFR §410.69(b); and
• 100-04, chapter 12, sections 140 through 140.4.4 (Claims Processing Manual).

 

 

4830. CLAIMS FOR ANESTHESIA SERVICES PERFORMED ON AND AFTER JANUARY

1, 1992

1. Billing Instructions.–Instruct providers to use the following modifiers when billing for

anesthesia services:

• “-AA” – Physician personally performed.
• “-QK”- Medical direction of two, three, or four concurrent anesthesia procedures

involving qualified individuals.

• “-AD” – Medically supervised by a physician for more than four concurrent

procedures.

Rev. 1690 4-573

4830 (Cont.) CLAIMS REVIEW AND ADJUDICATION PROCEDURES 01-01

• “-QX” – CRNA with medical direction by a physician.
• “-QZ” – CRNA without medical direction by a physician.
• “-QS” – Monitored anesthesiology care services (can be billed by a CRNA or a

physician).

• “–QY” – Medical direction of one CRNA by an anesthesiologist. This modifier

is effective for anesthesia services furnished by a CRNA (or AA) on or after January 1, 1998.

NOTE: For service performed prior to January 1, 1994, the following modifiers should be used in

place of modifier “-QK”:

• “-QJ” – Two concurrent procedures, medically directed by physician.
• “-QO”- Three concurrent procedures, medically directed by physician.
• “-QQ”- Four concurrent procedures, medically directed by physician.

Inform providers that the modifier for monitored anesthesia care (QS) is for informational purposes.

Instruct providers to report actual anesthesia time on the claim form.

1. Claims Processing Requirements.–Determine payment for anesthesia services in

accordance with §15018. You must be able to determine the uniform base unit that is assigned to

the anesthesia code and apply the appropriate reduction where the anesthesia procedure is medically

directed. You must also be able to determine the number of anesthesia time units from actual

anesthesia time reported on the claim, differentiating 15 minute time unit intervals for personally

performed anesthesia procedures and 30 minute time unit intervals for medically directed

procedures. Multiply allowable units by the anesthesia-specific conversion factor used to determine

fee schedule payment for the payment area.

1. Payment for Anesthesia for Multiple Surgeries.–Payment may be made for the anesthesia

services provided during multiple or bilateral surgery sessions. See §15018.E for discussion of the

payment rules for anesthesia to patients who undergo multiple, concurrent surgical procedures. See

• §4826-4827 for a definition and appropriate billing and claims processing instructions for multiple

and bilateral surgeries.

1. Billing for Anesthesia for Multiple Surgeries.–Instruct physicians, when billing for the

anesthesia services associated with multiple or bilateral surgeries, to report the anesthesia procedure

with the highest base unit value with the multiple procedures modifier “-51.” Report the total time

for all procedures in the line item with the highest base unit value.

If the same anesthesia CPT-4 code applies to two or more of the surgical procedures, have billers

enter the anesthesia code with the “-51” modifier and the number of surgeries to which the modified

CPT-4 code applies.

Price multiple anesthesia services using the base unit of the anesthesia procedure with the highest

base unit value and the actual time that extends over all procedures.

 

 

1. Payment at Personally Performed Rate.–Determine the fee schedule payment, recognizing

the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time if:

• The physician personally performed the entire anesthesia service alone; or
• The physician is involved with one anesthesia case with an intern or resident, the

physician is the teaching physician as defined in MCM §15016, and the service is furnished on or

after January 1, 1996; or

• The physician is continuously involved in a single case involving a student nurse

anesthetist; or

• The physician is continuously involved in one anesthesia case involving a CRNA (or

1998. AA) and the service was furnished prior to January 1, 1998. If the physician is involved with a

single case with a CRNA (or AA) and the service was furnished on or after January 1, 1998, you

may pay the physician service and the CRNA (or AA) service pursuant to the medical direction

payment policy in MCM §15018.

• The physician and the CRNA (or AA) are involved in one anesthesia case and the

services of each are found to be medically necessary. Documentation must be submitted by both

the CRNA and the physician to support payment of the full fee for each of the two providers. The

physician would report using the “AA” modifier and the CRNA would use the “QZ” modifier for

a nonmedically directed case.

1. Payment at the Medically Directed Rate.–Determine payment for the physician’s medical

direction service furnished on or after January 1, 1998 on the basis of 50 percent of the allowance

for the service performed by the physician alone. Medical direction occurs if the physician

medically directs qualified individuals in two, three or four concurrent cases and the physician

performs the activities described as follows:

• Performs a pre-anesthetic examination and evaluation;
• Prescribes the anesthesia plan;
• Personally participates in the most demanding procedures in the anesthesia plan,

including induction and emergence;

• Ensures that any procedures in the anesthesia plan that he or she does not perform are

performed by a qualified anesthetist;

• Monitors the course of anesthesia administration at frequent intervals;
• Remains physically present and available for immediate diagnosis and treatment of

emergencies;

• Provides indicated-post-anesthesia care.

The requirement that the physician participate in the most demanding procedures of the anesthesia

plan, including induction and emergence, was included at a time when general anesthesia was the

usual mode of practice for anesthesia services. However, since that time other types of anesthesia

care, such as regional anesthetics and monitored anesthesia care, have become more common. For

medical direction services furnished on or after January 1, 1999, the physician must participate only

Rev. 1690 15-13

15018 (Cont.) FEE SCHEDULE FOR PHYSICIANS’ SERVICES 01-01

in the most demanding procedures of the anesthesia plan, including, if applicable, induction and

emergence. For medical direction services furnished on or after January 1, 1999, the physician must

document in the medical record that he or she performed the pre-anesthetic exam and evaluation.

Physicians must also document that they provided indicated post-anesthesia care, were present

during some portion of the anesthesia monitoring, and present during the most demanding

procedures, including induction and emergence, where indicated.

For services furnished on or after January 1, 1994, the physician can medically direct two, three or

four concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs,

interns, residents or combinations of these individuals. The medical direction rules apply to cases

involving student nurse anesthetists if the physician directs two concurrent cases, each of which

involves a student nurse anesthetist or the physician directs one case involving a student nurse

anesthetist another involving a CRNA, AA, intern or resident.

If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia

examination and evaluation while another fulfills the other criteria. Similarly, one physician

member of the group may provide post-anesthesia care while another member of the group furnishes

the other component parts of the anesthesia service. However, the medical record must indicate that

the services were furnished by physicians and identify the physicians who rendered them.

A physician who is concurrently directing the administration of anesthesia to not more than four

surgical patients cannot ordinarily be involved in furnishing additional services to other patients.

However, addressing an emergency of short duration in the immediate area, administering an

epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of

an obstetrical patient, does not substantially diminish the scope of control exercised by the physician

in directing the administration of anesthesia to surgical patients. It does not constitute a separate

service for the purpose of determining whether the medical direction criteria are met. Further, while

directing concurrent anesthesia procedures, a physician may receive patients entering the operating

suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling

matters without affecting fee schedule payment.

However, if the physician leaves the immediate area of the operating suite for other than short

durations or devotes extensive time to an emergency case or is otherwise not available to respond

to the immediate needs of the surgical patients, the physician’s services to the surgical patients are

supervisory in nature. Do not make payment under the fee schedule.

See subsection J for a definition of concurrent anesthesia procedures.

1. Payment at Medically Supervised Rate.–Allow only three base units per procedure when

the anesthesiologist is involved in furnishing more than four procedures concurrently or is

performing other services while directing the concurrent procedures. An additional time unit can

be recognized if the physician can document he or she was present at induction.

1. Payment for Multiple Anesthesia Procedures.–Payment can be made under the fee

schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral

procedures. Payment is determined based on the base unit of the anesthesia procedure with the

highest base unit value and time units based on the actual anesthesia time of the multiple procedures.

15-14 Rev. 1690

01-01 FEE SCHEDULE FOR PHYSICIANS’ SERVICES 15018 (Cont.)

1. Payment for Medical and Surgical Services Furnished in Addition to Anesthesia

Procedure.–Payment may be made under the fee schedule for specific medical and surgical services

furnished by the anesthesiologist as long as these services are reasonable and medically necessary

or provided that other rebundling provisions (see §§4630 and 15068) do not preclude separate

payment. These services may be furnished in conjunction with the anesthesia procedure to the

patient or may be furnished as single services, e.g., during the day of or the day before the anesthesia

service. These services include the insertion of a Swan Ganz catheter, the insertion of central venous

pressure lines, emergency intubation, and critical care visits.

1. Anesthesia Time and Calculation of Anesthesia Time Units.–Anesthesia time means the

time during which an anesthesia practitioner is present with the patient. It starts when the anesthesia

practitioner begins to prepare the patient for anesthesia services in the operating room or an

equivalent area and ends when the anesthesia practitioner 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 for services furnished on or after January 1, 2000, the anesthesia

practitioner can add blocks of time around an interruption in anesthesia time as long as the

anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the

interruption.

Actual anesthesia time is reported on the claim. For anesthesia services furnished on or after January

1, 1994, compute time units by dividing reported anesthesia time by 15 minutes. Round the time unit

to one decimal place. Do not recognize time units for codes 01995 or 01996.

For purposes of this section, anesthesia practitioner means a physician who performs the anesthesia

service alone, a CRNA who is not medically directed, or a CRNA or AA, who is medically directed.

The physician who medically directs the CRNA or AA would ordinarily report the same time as the

CRNA or AA reports for the CRNA service.

1. Base Unit Reduction for Concurrent Medically Directed Procedures.–If the physician

medically directs concurrent medically directed procedures prior to January 1, 1994 reduce the

number of base units for each concurrent procedure as follows. For two concurrent procedures, the

base unit on each procedure is reduced 10 percent. For three concurrent procedures, the base unit

on each procedure is reduced 25 percent. For four concurrent procedures, the base on each

concurrent procedure is reduced 40 percent. If the physician medically directs concurrent

procedures prior to January 1, 1994, and any of the concurrent procedures are cataract or iridectomy

anesthesia, reduce the base units for each cataract or iridectomy procedure by 10 percent.

1. Monitored Anesthesia Care.–Pay for reasonable and medically necessary monitored

anesthesia care services on the same basis as other anesthesia services. Instruct anesthesiologists

to use modifier QS to report monitored anesthesia care cases. Monitored anesthesia care involves

the intraoperative monitoring by a physician or qualified individual under the medical direction of

a physician or of the patient’s vital physiological signs in anticipation of the need for administration

of general anesthesia or of the development of adverse physiological patient reaction to the surgical

procedure. It also includes the performance of a pre-anesthetic examination and evaluation,

prescription of the anesthesia care required, administration of any necessary oral or parenteral

medications (e.g., etropine, demerol, valium) and provision of indicated post-operative anesthesia

care.

Payment is made under the fee schedule using the payment rules in subsection B if the physician

personally performs the monitored anesthesia care case or under the rules in subsection C if the

physician medically directs four or fewer concurrent cases and monitored anesthesia care represents

one or more of these concurrent cases.

Rev. 1690 15-15

15018 (Cont.) FEE SCHEDULE FOR PHYSICIANS’ SERVICES 01-01

1. Definition of Concurrent Medically Directed Anesthesia Procedures.–Concurrency is

defined with regard to the maximum number of procedures that the physician is medically directing

within the context of a single procedure and whether these other procedures overlap each other.

Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if

an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients

and the remaining a Medicare patient, this represents three concurrent cases. The following example

illustrates this concept and guides physicians in determining how many procedures they are

directing.

EXAMPLE: Procedures A through E are medically directed procedures involving CRNAs and are

furnished after January 1, 1992. The starting and ending times for each procedure

represent the periods during which anesthesia time is counted. Assume that none of

the procedures were cataract or iridectomy anesthesia.

Procedure A begins at 8:00 a.m. and lasts until 8:20 a.m.

Procedure B begins at 8:10 a.m. and lasts until 8:45 a.m.

Procedure C begins at 8:30 a.m. and lasts until 9:15 a.m.

Procedure D begins at 9:00 a.m. and lasts until 12:00 noon.

Procedure E begins at 9:10 a.m. and lasts until 9:55 a.m.

Number of Concurrent Base Unit

Medically Directed Reduction

Procedure Procedures Percentage

A 2 10%

B 2 10%

C 3 25%

D 3 25%

E 3 25%

From 8:00 a.m. to 8:20 a.m., the length of procedure A, the anesthesiologist medically directed two

concurrent procedures, A and B.

From 8:10 a.m. to 8:45 a.m., the length of procedure B, the anesthesiologist medically directed two

concurrent procedures. From 8:10 to 8:20 a.m., the anesthesiologist medically directed procedures

A and B. From 8:20 to 8:30 a.m., the anesthesiologist medically directed only procedure B. From

8:30 to 8:45 a.m., the anesthesiologist medically directed procedures B and C. Thus, during

procedure B, the anesthesiologist medically directed, at most, two concurrent procedures.

From 8:30 a.m. to 9:15 a.m., the length of procedure C, the anesthesiologist medically directed three

concurrent procedures. From 8:30 to 8:45 a.m., the anesthesiologist medically directed procedures

B and C. From 8:45 to 9:00 a.m., the anesthesiologist medically directed procedure C. From 9:00

to 9:10 a.m., the anesthesiologist medically directed procedures C and D. From 9:10 to 9:15 a.m.,

the anesthesiologist medically directed procedures C, D and E. Thus, during procedure C, the

anesthesiologist medically directed, at most, three concurrent procedures.

The same analysis shows that during procedure D or E, the anesthesiologist medically directed, at

most, three concurrent procedures.

1. Anesthesia Claims Modifiers.—Instruct the physician to use the appropriate anesthesia

modifier to denote whether the service was personally performed, medically directed, or medically

supervised. See MCM §4830 for billing instructions for anesthesia services and modifiers.

15-16 Rev. 1690

01-01 FEE SCHEDULE FOR PHYSICIANS’ SERVICES 15033

15030. SUPPLIES

Make a separate payment for supplies furnished in connection with a procedure only when one of

the two following conditions exists:

1. HCPCS codes A4550, A4200, and A4263 are billed in conjunction with the appropriate

procedure in the Medicare Physician Fee Schedule Data Base (place of service is physician’s office);

or

1. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent

(including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or therapeutic

radionuclide (CPT code 79900). The procedures performed are:

• Diagnostic radiologic procedures (including diagnostic nuclear medicine) requiring

pharmaceutical or radiopharmaceutical contrast media and/or pharmocological stressing agent,

• Other diagnostic tests requiring a pharmacological stressing agent,
• Clinical brachytherapy procedures (other than remote afterloading high intensity

brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable source is

included in the TC RVUs), or

• Therapeutic nuclear medicine procedures.

 

 

15036. SITE-OF-SERVICE PAYMENT DIFFERENTIAL

Under the physician fee schedule, separate practice expense relative value units (PERVUs) are

calculated for procedures furnished in facility and in non-facility settings. Facility PERVUs are

applicable to procedures (except for therapy procedures) furnished:

• In hospitals;
• To patients in a Part A stay in a skilled nursing facility (SNF) identified on the HCFA 1500

claim form indicating Place of Service (POS) code 31; and

• In an ambulatory surgical center (ASC) that are included on the ASC approved list of

procedures.

Non-facility PERVUs are applicable to procedures furnished:

• To patients who are not in a Part A stay in a SNF identified on the HCFA 1500 claim form

indicating place of service (POS) code 32;

• In an ASC that is not included on the ASC approved list of procedures; and
• In all other facilities.

Non-facility PERVUs are applicable to therapy procedures regardless of whether they are furnished

in facility or non-facility settings.

 

16003. 1 CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNAs)
16004. General.–Anesthesia services furnished on or after January 1, 1992 by a qualified nurse

anesthetist are subject to the usual Part B coinsurance and deductible and are paid at the lesser of the

actual charge, the physician fee schedule, or the CRNA fee schedule.

1. Qualified Anesthetists.–For payment purposes, qualified anesthetists are CRNAs and

anesthesiologist assistants (AA). An AA is a person who:

• Is permitted by State law to administer anesthesia; and
• Has successfully completed a 6 year program for AAs of which 2 years consist of

specialized academic and clinical training in anesthesia.

A CRNA is a registered nurse who is licensed by the State in which the nurse practices and who:

• Is currently certified by the Council on Certification of Nurse Anesthetists or the

Council

on Recertification of Nurse Anesthetists, or

• Has graduated within the past 18 months from a nurse anesthesia program that meets

the standards of the Council of Accreditation of Nurse Anesthesia Educational Programs and is

awaiting initial certification.

1. Entity or Individual to Whom Payment is Made Under the CRNA Fee Schedule.–Payment

for the services of a qualified anesthetist may be made to the qualified anesthetist who furnishes

anesthesia services or to a hospital, physician, group practice, or ambulatory surgical center with

which the qualified anesthetist has an employment or contractual relationship. See §3060.1 for the

information and procedures necessary to permit payment to an employer. Follow the procedures in

• 3060.2 for the information necessary to permit payment to an entity or person with which the

qualified anesthetist has a contract.

1. CRNA Fee Schedule Payment.–Pay for the services of a qualified anesthetist only on an

assignment related basis. The assignment agreed to by the qualified anesthetist is binding upon any

other person or entity who claims 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 for payment for services of a qualified

Certified Registered Nurse Anesthetist (CRNA) Practice and Chronic Pain Management

Section 1861 of the Social Security Act defines services of a Certified Registered Nurse Anesthetist (CRNA) to mean anesthesia services and related care furnished by a certified registered nurse anesthetist, which the nurse anesthetist is legally authorized to perform as such by the State in which the services are furnished. This legislative statute forms the basis for the coverage of CRNA services by the Medicare program. Services meeting this definition are billable to Medicare when all medical necessity criteria have been met.

Anesthesia Services

The definition of anesthesia services is based on American Society of Anesthesiologists most recent set of practice guidelines (Anesthesiology 2002; 96:1004-17). Anesthesia services are divided into 2 categories; anesthesia and analgesia.

Category 1: Anesthesia, specifically including

General anesthesia

Regional anesthesia

Monitored anesthesia care (MAC), including deep sedation

Category 2: Sedation/analgesia, specifically including

Topical or local anesthesia

Minimal sedation

Moderate sedation/analgesia (“Conscious Sedation”)

Related Care

CMS Internet Only Manual (IOM) 100-04 – Medicare Claims Processing Manual, Chapter 12, Section 140.4.3 – Payment for Medical or Surgical Services Furnished by CRNAs lists additional services that a CRNA may bill for when they are related to anesthesia care provided. “Related to” is defined as occurring before, during or immediately after the administration of anesthesia. These services may include: insertion of central venous pressure lines, pain management, emergency intubation, and the pre-anesthetic examination and evaluation of a patient who does not undergo surgery.

Chronic Pain Management

Chronic pain is the common symptomatic manifestation of a wide range of underlying medical conditions. Treatment of the chronic pain disorder begins with a detailed medical assessment aimed at developing a diagnosis or diagnostic evaluation plan, which will then lead to an appropriate and comprehensive therapeutic plan. The assessment skills required for the evaluation of the chronic pain state and the development of the consequent plan of care not part of the CRNA training curricula. If the CRNA is an Advanced Registered Nurse Practitioner (ARNP) or Clinical Nurse Specialist (CNS), or working incident to a physician or Non-Physician Practioner (NPP), epidural injections may be reimbursed incident to the physician’s or NPP’s (NP, CNS, and PA) management of a patient with chronic pain when such services are medically reasonable and necessary.

Billing the Appropriate Contractor

The CMS Internet-Only Manual (IOM) 100-04 – Claims Processing Manual, Chapter 4, Sections 250.3.3.1 and 250.3.3.2 include information regarding billing for CRNA anesthesia services. The HCPCS code range in this section contains the anesthesia HCPCS codes that CRNAs may bill. This regulation does not include a HCPCS code range for the additional services that a CRNA may bill for as defined by CMS Internet Only Manual (IOM) Publication 100-04 – Medicare Claims Processing Manual, Chapter 12, Section 140.4.3. Critical Access Hospitals (CAH) should use the guidelines listed below to determine the appropriate form to use when billing for CRNA services.

If a CAH who meets the criteria for a pass-through exemption, is interested in selecting the Method II option, it can choose this option for all outpatient professionals except the Certified Registered Nurse Anesthetist (CRNA) and still retain the approved CRNA exemption for both inpatient and outpatient professional services of CRNAs. With an approved exemption, the CAH can choose to give up its exemption for both inpatient and outpatient professional services of CRNAs in order to include its CRNA outpatient professional services along with those of all other professional services under the Method II option. By choosing to include the CRNAs under Method II for outpatient services, the CAH loses its CRNA pass-through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case, the CAH would have to bill the Part B carrier for the CRNA inpatient professional services.

All payments for CRNA services are subject to cost settlement. If a CAH that meets the criteria for a pass-through exemption is not interested in selecting the Method II option, the CAH can still receive the CRNA pass-through under the standard option (Method I).

Method I

Billing requirements:

• Method I without a pass through exemption: bill professional services using CMS-1500 and technical services using CMS-1450
• Method I CMS with a pass thru – CMS-1450
• Type of Bill (TOB) = 85X and 11X.
• Revenue code 037X for CRNA technical services.
• Revenue code 0964 for professional services.

Method II – Receiving the CRNA Pass-Through

Billing requirements:

• CMS-1450
• TOB = 85X.
• Revenue code 037X for CRNA technical services.
• Revenue code 0964 for CRNA professional services.

Method II – Gave Up CRNA Pass-Through Exemption (or Never Had Exemption)

Billing requirements:

• CMS-1450
• TOB = 85X.
• Revenue code 037X for CRNA technical services.
• Revenue code 0964 for CRNA professional services.

 

 

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abinsights readers are invited to submit comments, questions, tips, and suggestions for articles on any subject related to billing, collections, coding, reimbursement, and compliance.  Send to:  Anesthesia Billing, Inc.,     P O Box 388, Newton, KS  67114-0388.  Phone 316-281-3700.  Fax 316-282-4322.

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Reasonable attempts have been made to be accurate.  However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ.  Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations.  For information specific to your practice, consult a qualified professional.

The information included in this publication is provided, among other things, to alert you to legal developments and should not be considered legal advice.  Specific questions about how this information affects your particular situation should be addressed to your attorney.

Editor:  Philip Blann (pblann@anesthesiabilling.com).