Doubling Down: When Two Anesthesia Providers Are Required

Summary: Every now and then, we need a little help from our friends. It's no surprise, then, that we occasionally come across two anesthesia providers in the same operating room at the same time. What does this mean from a compliance and compensation standpoint? Today's article dishes on the details.

In his heyday, no one was more proficient at belting out blues licks than Stevie Ray Vaughan. The Dallas prodigy produced sheer magic with his beaten-up Stratocaster, wowing audiences and receiving adulation from the world's other guitar greats. His two other bandmates were no slouches either. Calling themselves "Double Trouble," they masterfully held down the rhythm section while Stevie delivered blistering tones with surgical precision.

Sometimes, a little double trouble is what's needed in the hospital setting. There are those occasions when a surgeon will have a case with such acuity and level of difficulty that it calls for a double team of sorts from the anesthesia department. In these cases, two personally performing providers will be required to simultaneously deliver their anesthesia services during the operative session.

An Uncommon Occurrence

Most anesthesia services involve either a single provider or a care team of some type, with the latter potentially including a medical direction, teaching or relief scenario. These are common contingencies in anesthesia practices. What is not common is to have two providers in the room at the same time for most or all of the case. The fact that this is an unusual situation should inform us that the delivery of this model should be rare and not routine—at least from a billing perspective. Yes, there may be times when the clinical situation calls for "all hands on deck," but to bill for that extra pair of hands may be problematic—especially if a payer sees a group engaging in this care approach too often.

The above sentence raises a critical point and helps to explain why this scenario should be rare: it's because it potentially translates to more money. To clarify, the simultaneous presence of two full-time providers in the room may mean increased reimbursement from the payer. Because of this, the payer is going to highly scrutinize the claims; and, as always, medical necessity will be the primary focus. They're going to ask, why were two full-time providers needed in this particular case and is extra payment justified?

The Authoritative Sources

Some may wonder, is this even a thing? That is, are there circumstances that would actually allow us to bill full payment for two providers on the same case? The short answer is yes. That doesn't mean you will always get paid the additional amount, but the authoritative sources have recognized the principle of reimbursement for two full-time providers. Here's how the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50(B), elected to describe the scenario:

The physician and the CRNA (or anesthesiologist's assistant) 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 reports the AA modifier and the CRNA reports the QZ modifier.

Obviously, Medicare decided to use the example of an anesthesiologist and a CRNA to illustrate the issue. However, there is nothing in the above that would expressly preclude the services of two full-time anesthesiologists on the same case. The principle is the same.

The American Society of Anesthesiologists (ASA) has also weighed in on this issue. In its 2006 Relative Value Guide (RVG), the ASA confirmed that sometimes "it is necessary to have a second attending anesthesiologist assist with the preparation and conduct of the anesthesia . . . ." Interestingly, it then states the following relative to the claim of this second anesthesiologist: "Such services shall have a Base Value of 5 Units plus Time Units."

So, while recognizing the legitimacy of submitting two claims—with each reflecting the provider's time on the case—the ASA contended in 2006 that the second provider's claim was limited to only five base units. However, beginning with the 2007 RVG, the sentence referencing the five base units could no longer be found. This has led many to believe that the second anesthesiologist's claim is no longer limited to the five base units plus time, but rather it can be submitted with the base units assigned to the applicable anesthesia code plus the time units reflecting the amount of minutes the second provider spent on the case. This interpretation would seem to be supported by the "full fee" verbiage of the MCPM excerpt, provided above.

A Case in Point

Cases that call for two simultaneous anesthesia providers often involve massive traumas or high-acuity heart surgeries. Let's say the patient has a three-hour procedure involving an abdominal aortic aneurism (AAA), with a base unit value of 15. One anesthesiologist may be needed to monitor while his/her partner administers medications and tends to other vital tasks. Let's further assume that both were present for the entire case. In this situation, both providers are essentially personally performing in a concurrent manner. Here is how the case would break down from a claims perspective:

Similarly, if that same case involved a personally performing anesthesiologist who was present for the entire case and a non-medically directed CRNA who was there for two hours, the claims would be submitted as follows:

In both scenarios, the constant involves the submission of two claims—one for each of the providers—with each claim containing a modifier indicating he/she performed the case as if alone. What's interesting is that full base payment is allowed for both, even though only one of these providers would have performed the pre-anesthesia assessment (in non-emergent cases), which is one of the base unit payment components.

Now, all this raises the question of whether it is justifiable to seek full base unit reimbursement for the second provider, where such provider was only present for, say, 15 minutes of a three-hour case. Some groups have voluntarily elected in such situations to limit the base unit claim for that provider to 5 units. Other groups don't bill the second provider at all. One compliance attorney suggested it might be appropriate to only bill the second provider's time.

Documentation Protocol

Because the submission of two personally performed anesthesia claims relative to the same case is unusual and requires an extra layer of medical necessity support, the ASA has recommended that the claim of the second provider (whoever that is determined to be) should be accompanied by a second document. Here is how the ASA put it: "A service that is rarely provided, unusual, variable, or new may require a special report in determining medical appropriateness of the service." It goes on to specify that having a second attending anesthesiologist is a circumstance that should be substantiated by "Special Report."

We therefore recommend that, whenever you utilize the services of two simultaneous providers, and you intend to submit a claim for each, you have the second provider to fill out a document under the title "Special Report." (Medicare may require both providers submit such a report.) We further recommend that the provider list the unusual circumstances that required his/her additional presence. In addition, the report should state who requested the services of the second provider and what specific services that provider rendered. The provider should then sign and date the report.

If you have further questions about this topic or are in need of a Special Report template, please contact your account executive or reach out to us at info@anesthesiallc.com.