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Question: I’m preparing a claim involving a certified registered nurse anesthetist (CRNA) working without the direction of an anesthesiologist. What modifier would I use in this situation — and what modifiers would I use in other situations with or without direction?

New Mexico Subscriber

Answer: In this situation, you might need modifier QZ (Crna service: without medical direction by a physician.)

Medical direction modifiers indicate the level of supervision an anesthesiologist provides to a CRNA or an anesthesiologist assistant (AA). For a case to be considered medically directed, the anesthesiologist must perform the following activities and document them in the medical record:

• Perform a pre-anesthetic exam and evaluation
• Prescribe the anesthesia plan
• Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence, if applicable
• Ensure that any procedures in the anesthesia plan that they do not perform are performed by a qualified anesthetist
• Monitor the course of the anesthesia administration at frequent intervals
• Remain physically present and available for immediate diagnosis and treatment of emergencies
• Provide indicated post-anesthesia care

Although some payers do not require modifiers, for the payers that do, the following modifiers should be appended to the appropriate claim:

• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). All the above medical direction requirements must be met. This is reported on the anesthesiologist’s claim.
• QY (Medical direction of one certified registered nurse anesthetist (crna) by an anesthesiologist). All the above medical direction requirements must be met. This is reported on the anesthesiologist’s claim.
• AD (Medical supervision by a physician: more than four concurrent anesthesia procedures). This is reported on the anesthesiologist’s claim and may have limited reimbursement based on specific payer policies.
• QX (Crna service: with medical direction by a physician). This is reported on the CRNA or AA claim when the anesthesiologist reports a QK, QY, or AD.
• QZ (Crna service: without medical direction by a physician). This is used when the CRNA is practicing independently without medical direction.
• AA (Anesthesia Services performed personally by anesthesiologist). This is billed only when there is no CRNA involvement.

Using the correct modifier for medical direction is essential for submitting accurate claims and ensuring proper reimbursement.

Julie McDaniel, MHA, CPC, CANPC, Contributing Writer