Healthcare Fraud Shield’s Latest Article: Hazy on Anesthesia Modifiers?

For anesthesia services, there are many different modifiers that can and should be appended to the procedure codes in order to adequately describe the services.  Some modifiers are used to indicate who rendered the services and others are used to describe the patient’s condition during the surgery.  It is important to understand how these modifiers affect payment in many Payer’s systems, because inappropriate usage of these modifiers can lead to inappropriate payments.

Two Claims Can Be OK!

Some of the most common anesthesia modifiers are the following HCPCS modifiers [1]:

• GC – Service performed by a resident under the direction of a teaching physician
• QK – Medical direction of 3 or 4 concurrent anesthesia procedures
• QX – CRNA service – with medical direction by a physician
• QY – Medical direction of one CRNA by an anesthesiologist
• QZ – CRNA Service, without medical direction by a physician
• AA – Anesthesia services performed personally by an anesthesiologist

It is quite common for anesthesia to be performed by two separate providers: one CRNA (Certified Registered Nurse Anesthetist), AA (Anesthesiology Assistant), or Resident, and one supervising physician.  In these instances, you will see two claims submitted for the same service, each with the appropriate modifier indicating who rendered the service.  The CRNA or AA’s claim would use the QX modifier, a resident would use GC, and the supervising physician would use either QK or QY, depending on the number of individuals being supervised.  When two claims are submitted for the same service with these modifiers, claim payment systems are typically set to only pay 50% of the allowable rate on each claim. 

What Should Investigators look for?

What investigators should look out for is when there are two claims billed for the same service, but one of the modifiers appended is “AA”.  This means that the service was performed personally by the physician, and carries a 100% reimbursement rate.  It is not acceptable for the AA modifier to be billed with any of the other above modifiers for the same anesthesia service.  In fact, the OIG has listed this issue as part of their 2013 Workplan for Medicare Part B claim reviews [2]. 

Another combination to look out for is when two claims billed for the same service, where one has the QZ modifier and the other has QK or QY.  This is also unacceptable because the QZ modifier indicates the CRNA provided the services unsupervised, and there should not be a separate claim from a supervising physician.

Physical Status Modifiers

Another set of Anesthesia Modifiers are the Physical Status modifiers P1 through P6.  These modifiers describe the patient’s condition with P1 signifying a normal healthy patient through P5 which is for a moribund patient who is not expected to survive without the operation.  (P6 is for a declared brain-dead patient whose organs are being removed for donor purposes.)  Many commercial payers will allow for additional payment on claims where modifiers P3 through P5 are appended to the claim [3].  However, Medicare at this time does not [4].  Investigators should be on the lookout for providers that bill an excessive amount of modifiers P3 through P5 as it could be an indication of inappropriate billing.

Healthcare Fraud Shield’s FWA Software Package can identify anesthesiologists and other providers that are outliers among their peers – and help your company identify the schemes discussed in today’s newsletter.  Contact us today to learn more!

 References:

[1] HCPCS Level II Manual, Expert Edition, 2013

[2] OIG Workplan, 2013, page 21. 

[3] Regence Blue Cross Blue Shield Anesthesia Reimbursement Policy

[4] WPS Medicare Part B Modifier Fact Sheet