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Spring 2009

The “Care Team” Billing Rules

Hal Nelson, CPC
Director of Compliance, ABC

Most people know the seven documentation requirements for medical direction (presence at inductionemergence, immediate availability, etc.), but how many understand the nuances of billing for a care team service? The information below provides a guide to navigating through this challenging issue.


An attending anesthesiologist overseeing a single resident bills using the -GC modifier with payment at 100% of a personally performed case, as long as the CMS teaching physician guidelines are met. An alternative CMS billing rule involves the oversight of two concurrent resident cases. Here the attending anesthesiologist can oversee two residents at once and bill for the full base units of each case, while only billing for the time that the physician was present in each of the rooms respectively. In this scenario, the physician would bill using the –GC teaching physician modifier on each case, just as an attending would bill for a 1:1 resident case, only with bbreviated minutes (in-room time only) in each of the two concurrent rooms. Billing using this methodology requires meticulous documentation, as discontinuous time needs to be documented on the anesthesia records throughout the duration of each case. The CMS teaching physician requirements also need to be met in this scenario. Minor surgical procedures performed by a resident (lines, etc.) can be billed out under the attending anesthesiologist, but only if the anesthesiologist documents physical presence during the entire minor surgical procedure. Medical direction of more than one case (involving any combination of residents, SRNAs, AAs or CRNAs) can be billed out by the anesthesiologist with the –QK modifier and payment is 50% of the personally performed rate in each case. The hospital does not receive a professional payment for any resident service, but is instead paid indirectly through the Graduate Medical Education (GME) program.

Student Registered Nurse Anesthetists (SRNAs)

Medical direction of a SRNA is limited by CMS to a maximum of 2 concurrent cases (at least one involving a SRNA). The ASA recently issued a position paper that suggests not exceeding a 1:1 ratio with a SRNA. A 1:1 Anesthesiologist/SRNA concurrency ratio is billed out by the anesthesiologist with the –AA modifier and is paid at 100% of the personally performed rate per CMS. 1:2 ratios are billed out as medical direction by the anesthesiologist with the –QK modifier, and payment is at 50% of the personally performed rate to the anesthesiologist in each case. SRNAs are ineligible for billing purposes, and receive no direct payment from insurance. There is no specific CMS rule addressing minor surgical procedures (lines, etc.) performed by a SRNA under the oversight of an anesthesiologist. Payment is left to the discretion of the individual insurance carrier in this scenario.

Anesthesiology Assistants (AAs)

AAs are utilized in care team environments most frequently in areas where there are Anesthesiology Assistant programs offered, such as Georgia, Ohio, Missouri and Florida. Unlike CRNAs, who are permitted to perform non-medically directed anesthesia, AAs cannot. Anesthesiology Assistants must be medically directed and payment is at 50% of the personally performed rate to both the Anesthesiologist and the AA. For billing purposes, the modifiers submitted are –QK and –QX respectively.

Certified Registered Nurse Anesthetists (CRNAs)

CRNAs have multiple billing options when providing anesthesia. A anesthesiologist medically directing a single CRNA case is billed out with the –QY/-QX modifiers respectively, while an anesthesiologist medically directing multiple CRNAs cases is billed out with the –QK/-QX modifiers. In both scenarios, payment is at 50% of the personally performed rate to each provider. A medically supervised case involving an anesthesiologist and a CRNA is billed out with the –AD and –QX modifiers respectively and payment is limited to 3-4 total units to the anesthesiologist per CMS (4 units if documented presence at induction). The CRNA is still paid at 50% of the personally performed rate in this instance. CRNA’s who perform non-medically directed anesthesia, most commonly seen in one of the “opt-out states”, are billed out with the –QZ modifier under the CRNA’s name and payment is 100% of the personally performed rate. Some Medicare carriers have also endorsed the –QZ modifier for “incomplete medical direction” when the group employs both the anesthesiologist and the CRNA.