The Clinical Classroom: Specific Scenarios for the Anesthesia Teacher
Summary: It's back to the chalkboard as we continue our review of the teaching rules for anesthesia providers. In today's article, we will focus primarily on case configuration, payment issues and documentation requirements. So, open up your notebooks and have your pencils at the ready!
Two weeks ago, we presented the first in a two-part series of articles devoted to the intricacies and oddities of billing while teaching. We learned that an anesthesiologist can get paid at the personally performed rate, even when running two resident cases. We discussed the two-case principle and the meaning of "resident," from a Medicare perspective. Finally, we looked at some historical changes in the billing rules for cases involving residents and student nurses.
In today's article, we want to address some additional rules and circumstances one must consider when it comes to the submission of claims on behalf of the anesthesia teacher. To that end, we offer, below, some representative teaching scenarios.
Anesthesiologist with Resident and CRNA
As discussed in our previous article, a teaching anesthesiologist can run up to two rooms where either a resident or SRNA is involved. Let us say that one room has a resident and the other has a CRNA. In this scenario, the anesthesiologist would bill personal performance in the resident case and bill medical direction in the CRNA case. The CRNA would receive the normal 50 percent of the allowable for his/her service. Therefore, assuming the CRNA is a member of the anesthesiologist's group, the group would realize 100 percent reimbursement of the allowable in both cases.
Anesthesiologist with SRNA
As we learned earlier, a teaching CRNA working with two SRNA cases receives full reimbursement on both cases. Similarly, a teaching anesthesiologist working with two resident cases receives the same allowance. It is strange to learn, then, that this full-payment principle does not apply where the anesthesiologist is intermittently involved in two SRNA cases—or even one, for that matter. In such a scenario, the anesthesiologist is said to be medically directing the SRNA(s), and thus would only receive 50 percent reimbursement as to each such case. The group would not receive any payment reflecting the work of the SRNA.
There is one exception to the above rule, as established by the U.S. Code of Federal Regulations at 42 § 414.46. In a case where the anesthesiologist is involved in just one case, and that case involves an SRNA, there is a potential for obtaining full reimbursement for the anesthesiologist. How? Instead of merely medically directing the SRNA, the anesthesiologist must be present with the SRNA for the entire case. In that event, the anesthesiologist can be said to be personally performing and can therefore bill the case with the AA modifier. However, you must ensure that your documentation supports this circumstance when it occurs. We strongly recommend that you clearly denote "present for entire case" or similar verbiage on the record. This will give our staff a heads-up to bill the claim as personally performed and will protect you in the event of an audit.
Billing for Four Cases
In spite of the two-case principle referenced in the previous article of this series, there is a scenario in which a teaching anesthesiologist can bill for up to four concurrent cases—even where an SRNA is in one or more of those rooms. "But you said . . ."—yes, I know, but it's important to establish the basic principles first, and then look at the exceptions. Furthermore, this particular exception is one in name only, as it involves some semantic sleight of hand.
Back in late 2009, the ASA published an extensive document outlining the teaching scenarios they believed were consistent with the 2010 Medicare Physician Fee Schedule (PFS) Final Rule. According to that document, an anesthesiologist may bill medical direction in up to four SRNA cases, but only where there is a CRNA perpetually present with the SRNA in each SRNA room. In that way, the anesthesiologist is acting more as the medical director of the CRNA than the SRNA. This allows you to bill QK in each of the rooms, while the CRNA is allowed to bill QX—meaning 100 percent payment for the group on each case where the CRNA is a member of your group. The CRNA's documentation will need to support their continuous presence with the patient throughout the case.
The Teaching CRNA
The Medicare Learning Network (MLN) article cited in our previous offering on this topic advises the following: "To bill the base units for each of the two cases, the teaching CRNA must be present with the student during the pre and post anesthesia care for each case." Accordingly, the teaching CRNA should document in the record his/her presence for these two events relative to each case. Furthermore, the CRNA should document that he/she was involved in no other activities outside of the supervision of the SRNA cases. As already noted, the CRNA may also bill the time reflected in both cases.
Billing for Procedures
The question often arises: Can the teacher get paid for ancillary procedures performed by the resident or SRNA? The short answer to that question is yes. There are, of course, a few strings attached. One must remember that invasive line or post-op pain block placements are surgical services, i.e., type of service (TOS) 2, rather than anesthesia (TOS 7) and are thus subject to different teaching rules.
The Medicare Claims Processing Manual (MCPM), Chapter 12, Section 100.1.2, states the following:
For procedures that take only a few minutes (five minutes or
less) to complete, e.g., simple suture, and involve relatively little decision
making once the need for the operation is determined, the teaching surgeon must
be present for the entire procedure in order to bill for the procedure.
Based on this language, we recommend that the anesthesia teacher be present for the entirety of a separately billable procedure performed by the resident or SRNA. The teacher should also document such presence in the medical record.
Documentation, Generally
The teaching rules also contain certain requirements concerning the teaching anesthesiologist's presence in connection with a resident case. The teacher must be present for the "most critical or key portions" of the case (to include induction and emergence, where applicable). In addition, CMS requires that the teaching anesthesiologist remain "immediately available." Consequently, it is imperative that these two elements are documented within the anesthesia record by the teacher. We recommend you include the above quotations as part of your record attestations in teaching cases.
In addition to the above attestations, the anesthesia record should contain the teacher's signature, in addition to that of the learner. The record should make clear the resident or student status of the learner.
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The foregoing is not intended to be an exhaustive treatment of the teaching rules in the context of anesthesia. Therefore, if you have questions involving other teaching-related issues that you may encounter in your practice, or if you would like additional clarification on the above scenarios, please reach out to your account manager or contact us at info@anesthesiallc.com.