ModifiedAlliance Health (LME-MCO)Policy 1L-1
Anesthesia Services
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Defines coverage, requirements, and limits for Medicaid anesthesia services in North Carolina, including types of anesthesia, time definitions, EPSDT exceptions for beneficiaries under 21, and provider/billing considerations. Affects NC Medicaid beneficiaries and providers who deliver or bill for anesthesia services.
Policy Summary
PayerAlliance Health (LME-MCO)
PolicyAnesthesia Services
Policy CodePolicy 1L-1
Change TypeMaterial revision (supervision limit updated)
Effective DateOct 1, 2003
Last ReviewAug 15, 2023
Next Review DateN/A
Key ActionAppend the appropriate anesthesia modifier (AA, QY, QK, AD, QZ, QX, QS) for each billed anesthesia service and follow medical direction rules when applicable.
SourceLink
POLICY UPDATE CHANGES
Changed number of anesthesia assistants an anesthesiologist may supervise from two to four.
Clarified billing instructions that Institutional Claims must follow National Uniform Billing Guidelines and all claims must comply with National Coding Guidelines.
Attachment B: Billing Guidelines for Anesthesia Services with and without Medical Direction was removed.
EPSDTEPSDT provisions for beneficiaries under 21
continuousAnesthesia time defined
4Max concurrent patients supervised
patient-controlledNot covered
1L-2, 4A, 1E-5Related policies
Coverage Criteria and Medical Necessity
inv-01: General coverage criteria
Medicaid covers anesthesia services when medically necessary and meeting general criteria.
ALL of the following
- The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs.
- The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.
- The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.
inv-02: General medical necessity criteria for coverage
General medical necessity criteria for coverage:
ALL of the following
- Service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs.
- Service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide.
- Service is not primarily for the convenience of the beneficiary, caretaker, or provider.
inv-03: Service inclusions, exclusions, and billing
Service-specific coverage stance and exceptions:
Global package: General anesthesia, regional anesthesia, and Monitored Anesthesia Care (MAC) are considered a global package and include preoperative and postoperative visits, anesthesia services during the procedure, administration of IV fluids including blood/products, intra-operative laboratory evaluations, and routine intraoperative monitoring and interpretation. These services are not reimbursed separately unless unrelated and billed with modifier 59.
Separately billable monitoring/services
- Pulmonary artery catheter insertion (billed separately with modifier 59).
- Central venous catheter insertion (billed separately with modifier 59).
- Intra-arterial catheter insertion (billed separately with modifier 59).
- Nerve blocks for postoperative pain relief (single injections and continuous catheters) (billed separately with modifier 59).
- Ultrasound-guided central venous access and assisted peripheral nerve blockade (billed separately with modifier 59).
- Transesophageal echocardiography (TEE) monitoring and interpretation (billed separately with modifier 59).
Pain management: Peripheral nerve blocks, plexus blocks, and epidural and caudal blocks administered for postoperative or intractable pain are covered (bill appropriate CPT; use modifier 59 when performed primarily for postoperative pain).
Local anesthesia injected into cutaneous/subcutaneous tissue is included in the procedure fee; no separate reimbursement when performed by the operating physician.
Not covered
- Patient-controlled anesthesia is not covered.
- Moderate (conscious) sedation is separate from general anesthesia, MAC, or regional anesthesia and is addressed in clinical coverage policy 1L-2 (not covered under this anesthesia global package).
inv-04: Medical direction requirements
Medical direction billing requirements:
ALL of the following
- Perform the pre-anesthesia evaluation and exam.
- Prescribe the anesthesia.
- Participate personally in induction of and emergence from the anesthesia procedure.
- Ensure any part of the anesthesia plan not personally performed is performed by a qualified CRNA or anesthesiologist assistant.
- Monitor the course of anesthesia administration at frequent intervals.
- Remain physically present and available in the operating suite to provide diagnosis and treatment in an emergency.
- Provide post-anesthesia care, including direct patient care by the anesthesiologist or a qualified provider under the anesthesiologist's supervision.
inv-05: General not-covered criteria
General exclusion criteria:
ANY of the following
- The beneficiary does not meet the eligibility requirements listed in Section 2.0.
- The beneficiary does not meet the criteria listed in Section 3.0.
- The procedure, product, or service duplicates another provider's procedure, product, or service.
- The procedure, product, or service is experimental, investigational, or part of a clinical trial.
inv-06: Coverage criteria for anesthesia services
Coverage is provided with criteria for qualifying circumstances, stand-by services, E/M coding interactions, consultations, and provider billing eligibility.
Qualifying circumstances: Anesthesia provided under particularly difficult circumstances (extraordinary patient condition, notable operative conditions, or unusual risk factors) is reported as one additional unit in addition to the primary procedure and not reported alone.
Extreme age: Report qualifying circumstance for beneficiaries under 1 year and over 70 years of age.
Total body hypothermia and controlled hypotension: Anesthesia complicated by total body hypothermia or by controlled hypotension is covered when these conditions are due to the type of surgery being performed (e.g., open heart or brain surgery).
Emergency conditions: Report anesthesia complicated by an emergency when delay in surgery may significantly increase threat to life or body part.
Anesthesia stand-by: Stand-by services are covered for high-risk deliveries when the appropriate diagnosis code is used and no other anesthesia services are provided (see obstetrics policy 1E-5).
E/M and anesthesia global package: The global anesthesia package includes preoperative evaluation, prescription of the anesthetic plan, provision of anesthesia (general, regional, or MAC), routine intra-op monitoring and labs, administration of IV fluids including blood/products, immediate postoperative care, and postoperative visit. Critical care and ventilator E/M services beyond the immediate postoperative period are covered separately and must be billed with modifier 25.
Termination of surgery billing: If surgery is terminated after the preanesthesia evaluation, an E/M may be billed if E/M criteria are met and documented. If induction of anesthesia begins, reimbursement is based on CPT procedure base units plus actual time.
Consultations must be requested by the attending physician or other appropriate source and documented; routine preoperative visits are not consultations and CPT E/M consultation definitions apply.
Provider eligibility and qualifications: Providers must meet Medicaid participation qualifications, have a current DHHS Provider Administrative Participation Agreement, bill only within scope of clinical practice, and comply with CRNA/Anesthesiologist Assistant qualifications and supervision limits as referenced in state and federal regulations (anesthesiologist may supervise up to four anesthesiologist assistants).
Multiple procedures on same date: For multiple surgical procedures on the same date, reimbursement is based on the highest base unit procedure plus actual anesthesia time; medical records must be provided on request.
Epidural catheter follow-up: Only one follow-up code for daily hospital management of continuous epidural or subarachnoid drug administration (01996) is allowed per day and includes visit, removal/adjustment, dose calculation, and drug administration.
Compliance requirements: Providers must comply with EPSDT exceptions for beneficiaries under 21, all applicable agreements, laws, HIPAA, record retention, NC Medicaid clinical coverage policies, and CMS/DHHS guidance.
inv-07: Anesthesia billing and documentation criteria
Provider compliance and documentation criteria
ALL of the following
- Providers must comply with all applicable agreements, federal, state and local laws and regulations including HIPAA, record retention, NC Medicaid clinical policies, guidelines, and CMS/DHHS publications.
- If the primary surgeon's claim is denied because federal regulations were not met, related anesthesiologist claims will also be denied.
Documentation: Medical records must document pre-anesthetic examination/evaluation, beginning and end times of anesthesia, monitoring of vital signs, any postoperative anesthesia notes, documentation to support billed codes, and indicate medical direction to establish medical necessity and correct billing.
Modifier usage and claim types: Append the appropriate anesthesia modifier (AA, QY, QK, AD, QZ, QX, QS as applicable) to anesthesia CPT codes for each billed anesthesia service. When MAC is billed append QS plus the appropriate specialty modifier. Use modifier 59 when a procedure is unrelated and billed separately. Claims may be Professional (CMS-1500), Institutional (UB-04), or Dental (ADA); Institutional claims must follow National Uniform Billing Guidelines and all claims must comply with National Coding Guidelines.
Provider-specific billing rules
- Anesthesiologist assistants reimbursed at 50% of the physician fee.
- When a CRNA is employed by a hospital, the CRNA professional charges are billed on the hospital's professional claim form and modifier QX must be appended as specified; facility charges on UB-04 with revenue code 37X placement as required.
- When a CRNA is employed by an anesthesiologist, the anesthesiologist bills medical direction appending QK or QY and the CRNA bills separately with QX appended; provider number placement follows CMS-1500 instructions.
inv-08: Reimbursement calculations
Payment calculation and modifier-dependent reimbursement rules:
Anesthesiologist personally performed: Payment = (Base units + time units) × physician maximum allowed amount (use AA modifier).
Anesthesiologist medically directing CRNA/AA: Payment = (Base units + time units) × 50% of physician maximum allowed amount (use QY or QK for physician; CRNA uses QX).
Anesthesiologist supervising >4 CRNAs: Physician allowable = 45 base units for every procedure being supervised; a one-time 15-minute block may be billed if documented presence at induction (use AD modifier).
CRNA not medically directed: Payment = (Base units + time units) × CRNA maximum allowed amount (use QZ modifier).
Anesthesiologist Assistant reimbursement: Anesthesiologist Assistant payment = (Base units + time units) × 50% of physician maximum allowed amount (no modifier).
Time billing adjustment: If surgery is delayed and anesthesia provider is not in constant attendance, reduce billed time to reflect actual time spent with the beneficiary.
inv-09: Service billing rules and limits
Service-specific billing rules and limits:
Obstetric anesthesia time cap: Maximum unit limitation of 180 units (minutes) per date of service applies for specified obstetric anesthesia procedures. Units billed exceeding 180 will be cut back to 180 unless additional units are supported by medical records.
01996 daily management: Code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration) is allowed once per day and includes all related services performed that day; it does not require anesthesia modifiers and may be billed by all physician specialties.
Pain management billing: Pain management procedures are not reimbursable by time; submit the appropriate CPT codes and bill units corresponding to number of services; use modifier 59 when performed primarily for postoperative pain to indicate separate reportable service.
Sterilization billing rules: Sterilization anesthesia CPT codes must be billed with ICD-10-CM diagnosis code Z30.2 and modifier FP; CPT codes for sterilization include 00840, 00851, and 00921. When sterilization is billed with labor and delivery, sterilization reimbursement is cut back to a flat fee (cutback pricing applies).
inv-10: Anesthesia coverage criteria and billing rules
Reimbursement and billing rules for anesthesia providers and combinations of delivery with sterilization procedures.
CRNA payment not medically directed: If the CRNA is not medically directed, payment = (Base units + time) × CRNA maximum allowed amount (use QZ modifier).
CRNA payment medically directed: If the CRNA is medically directed by an anesthesiologist, payment = (Base units + time) × 50% of physician maximum allowed amount (use QX modifier).
Anesthesiologist Assistant payment: Anesthesiologist Assistant reimbursement = (Base units + time) × 50% of physician maximum allowed amount (no modifier used).
Time adjustment when not in constant attendance: If the provider is not in constant attendance due to surgery delay, reduce billed time to reflect actual time spent with the beneficiary.
Sterilization with delivery: When sterilization is billed in addition to a delivery (examples: 01960, 01961, 01967, 01968, 01969, 00840, 00851), sterilization will have cutback pricing applied; both services are allowed with the cutback pricing rules. Some delivery/sterilization codes use flat 1-unit rules per code as specified in Attachment B.
Time unit rules for delivery/sterilization codes: Certain delivery and sterilization codes have special time-unit rules (e.g., 01967 may use a flat 1 unit; other codes follow 1 minute = 1 unit), and cutback pricing applies when sterilization is billed with delivery.
Coding, Time Reporting, and Procedure Codes
Provider Responsibilities, Prior Approval, and Billing Actions
Prior Authorization
Prior approval and EPSDT
If the service, product, or procedure requires prior approval, beneficiaries under 21 are still subject to the prior approval requirement. Providers must follow EPSDT exception guidance where applicable; see the NCTracks Provider Claims and Billing Assistance Guide and the NC Medicaid EPSDT provider resources for details and submission instructions: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html and https://medicaid.ncdhhs.gov/
- When a surgical procedure requires prior approval, it is the surgeon's responsibility to obtain that prior approval.
- Prior approval requests and supporting health records must be submitted to the DHHS Utilization Review Contractor and must demonstrate the beneficiary meets the specific policy criteria.
Billing Rule
Modifier and billing actions
Append the single modifier that most accurately describes the anesthesia service each time anesthesia is billed. For all anesthesia claims, follow the modifier instructions in Attachment B and appendix guidance in this policy.
- One of the following must be appended to the anesthesia CPT code: AA, QY, QK, AD, QZ, QX.
- When billing Monitored Anesthesia Care (MAC) indicated by QS, append QS plus the appropriate provider-level modifier (AA, QK, or QY for anesthesiologists; QX or QZ for CRNAs).
- Anesthesiologist assistants are reimbursed at 50% of the physician fee.
Billing Rule
Modifier and supervision billing actions
Follow modifier-specific rules for medical direction, supervision, and services without direction. Use the modifier(s) that reflect the supervision level and concurrent case volume.
- AA = service personally performed by anesthesiologist.
- QY = medical direction of 1 CRNA/AA by an anesthesiologist (used when anesthesiologist medically directs).
- QK = medical direction of 2–4 concurrent anesthesia procedures involving qualified individuals.
- AD = medical supervision by a physician for more than four concurrent anesthesia procedures (anesthesiologist billed AD; anesthesiologist reimbursed 45 base units per supervised procedure and may bill a one-time 15-minute block if presence at induction is documented).
- QZ = CRNA service without medical direction by a physician.
- QX = CRNA service with medical direction by a physician.
- When MAC is billed the anesthesiologist must append AA, QK, or QY in addition to QS; CRNAs must append QX or QZ in addition to QS.
Documentation Required
Claim form population rules
Populate claim forms based on employment relationship and facility billing rules. Follow CMS form block conventions and place provider and facility numbers as specified to avoid denials.
- CRNA employed by a hospital/facility: hospital bills professional charges on CMS-1500; hospital billing provider number in block 33; CRNA attending number in attending area of block 33; facility charges on UB-04 with revenue codes in the 37X range (facility charges only); CRNA CPTs append QX and anesthesiologist appends QY or QK for medical direction.
- CRNA employed by an anesthesiologist: anesthesiologist bills medical direction on physician claim with QK or QY in block 33; CRNA services billed on a separate CMS-1500 with QX appended; enter group provider number in block 33 and CRNA attending/provider numbers in attending field.
- Anesthesiologist assistant employed by a hospital/facility: hospital bills professional charges on CMS-1500 with hospital billing number in block 33 and assistant attending number in attending area; facility charges on UB-04 with 37X revenue codes; anesthesiologist appends QY or QK.
- Anesthesiologist assistant employed by an anesthesiologist: anesthesiologist bills medical direction with QK or QY; anesthesiologist assistant services billed on a separate CMS-1500 without a modifier (appending a modifier will cause denial).
- If the hospital bills CRNA professional charges, CRNA professional charges must not be included in the facility 37X revenue code.
Billing Rule
Anesthesia provider billing modifiers and payment calculations
Payment calculations depend on provider type and modifier used. Time billed must reflect actual attendance; reduce billed time if provider is not in constant attendance.
- Anesthesiologist personally performed (AA): (Base units + time) × physician maximum allowed amount = physician payment.
- Anesthesiologist medically directs CRNA/AA (QY/QK): (Base units + time) × 50% of physician maximum allowed amount = physician payment.
- Anesthesiologist medically supervises >4 CRNAs (AD): physician allowable = 45 base units per procedure; may bill one-time 15-minute block if induction presence is documented.
- CRNA not medically directed (QZ): (Base units + time) × CRNA maximum allowed amount = CRNA payment.
- CRNA medically directed (QX): (Base units + time) × 50% of physician maximum allowed amount = CRNA payment.
- Anesthesiologist assistant reimbursement: (Base units + time) × 50% of physician maximum allowed amount (no modifier).
Definitions and Modifier Meanings
Anesthesia services — definition of included care components
Included care componentsAnesthesia services include preanesthesia evaluation, intraoperative anesthesia care, interpretation of intraoperative lab tests, administration of IV fluids/blood, routine monitoring, immediate post-anesthesia care, and postoperative visit when applicable.
Types of anesthesia includedServices include general anesthesia, regional anesthesia, and monitored anesthesia care (MAC).
Monitoring and supportive careRoutine monitoring examples include ECG, temperature, blood pressure, pulse oximetry, capnography, end-tidal gas analysis, and other intraoperative monitoring included in the global package.
Anesthesia time — continuous physical presence definition
Continuous physical presenceAnesthesia time requires the continuous actual physical presence with the patient by the anesthesiology physician, resident, CRNA, or anesthesiologist assistant; the clinician must be in constant attendance during the time billed.
Start and end triggersTime starts when the clinician begins to prepare the patient for anesthesia in the OR or equivalent and ends when no longer in personal attendance (patient safely under postoperative supervision).
Documentation implicationBilled time must reflect continuous personal attendance and is subject to medical record review upon request.
Moderate (conscious) sedation — distinction from anesthesia and supervising providers
Distinct serviceModerate (conscious) sedation is separate and distinct from anesthesia and may be administered or supervised by non-anesthesia-credentialed providers when the supervising physician is credentialed to provide such services at the practice site.
Provider supervisionWhen MAC or general/regional anesthesia is intended, the policy treats those as anesthesia services requiring anesthesia personnel rather than moderate sedation rules.
Billing guidance referenceRefer to related policy 1L-2 for details on moderate (conscious) sedation.
General anesthesia — definition and characteristics
Definition characteristicsGeneral anesthesia is a controlled and reversible state of unconsciousness with possible loss of protective reflexes, amnesia and analgesia, and may include muscle relaxation.
Required activitiesIncludes administration and dosing of pharmacologic agents, intra-operative monitoring, treatment of adverse reactions, IV fluids/blood administration, interpretation of intra-op labs, and provision of postoperative anesthesia care.
Presence requirementNecessitates continuous actual presence of an anesthesiologist, resident, CRNA, or anesthesiologist assistant supervised by an anesthesiologist and performance of a preanesthetic exam and prescription of care.
Regional anesthesia — definition and included procedures
Definition and scopeRegional anesthesia produces loss of sensation or motor function to a body region via central neuraxis, nerve plexus, or peripheral nerves and includes intra-operative monitoring and ability to convert to general anesthesia if necessary.
Care componentsIncludes preanesthetic exam and evaluation, prescription of anesthesia care, administration of necessary medications, monitoring, and indicated postoperative anesthesia care.
Presence requirementRequires continuous actual presence of an anesthesiologist, resident, CRNA, or anesthesiologist assistant supervised by an anesthesiologist.
Monitored Anesthesia Care (MAC) — definition and monitoring expectations
Definition of MACMonitored Anesthesia Care (MAC) involves intra-operative monitoring of vital physiological signs in anticipation of need for general anesthesia or adverse physiological reaction.
Monitoring expectationsRequires careful and continuous evaluation of vital functions and recognition/treatment of adverse changes; includes preanesthetic exam, prescription of anesthesia care, medication administration, and postoperative care.
Presence requirementMAC necessitates the continuous actual presence of an anesthesiologist, resident, CRNA, or anesthesiologist assistant supervised by an anesthesiologist.
Local anesthesia — definition and inclusion in procedure payment
DefinitionLocal anesthesia is injection into cutaneous/subcutaneous tissue providing loss of pain sensation in a limited area.
Payment implicationAdministration of local anesthesia is included in the procedure fee; no separate reimbursement if performed by the operating physician.
ScopeLocal, field, or regional block performed by the operating physician is considered part of the operative procedure fee.
Medical direction — definition of tasks the anesthesiologist must perform when directing
Definition of medical directionMedical direction occurs when the anesthesiologist is physically and personally involved in the beneficiary's care simultaneously with the CRNA or anesthesiologist assistant and performs specified tasks.
Required tasksTasks include performing pre-anesthesia evaluation and exam, prescribing the anesthesia, participating in induction and emergence, ensuring qualified personnel perform delegated parts, monitoring at frequent intervals, remaining physically present in the operating suite, and providing post-anesthesia care.
Concurrent patient limitAnesthesiologists may direct anesthesia for no more than four concurrent surgical patients per policy guidance (see modifiers and supervision rules).
Qualifying circumstance — definition and impact (one additional anesthesia unit)
Definition of qualifying circumstanceQualifying circumstances are conditions (extraordinary patient condition, notable operative conditions, unusual risk factors, emergency, extreme age, total body hypothermia, controlled hypotension) that warrant reporting one additional anesthesia unit in addition to the primary procedure.
Reporting limitationQualifying circumstance is reported as one unit in addition to the primary procedure and is not reported alone.
ExamplesExamples include beneficiaries under 1 year or over 70 years, total body hypothermia when related to surgery type, controlled hypotension due to surgery, and emergency conditions where delay would significantly increase threat to life or body part.
Medical record documentation — required documentation elements to support services
Required documentation elementsMedical records must document the pre-anesthetic examination and evaluation, anesthesia beginning and end times, monitoring of vital signs, and any postoperative anesthesia notes to support services rendered.
Support for billed codesDocumentation must support the codes reported on the claim form to indicate services were provided and must indicate medical direction where applicable.
Use in medical necessity reviewMedical record documentation is reviewed to determine medical necessity and to verify that services were billed correctly; records must be provided upon request.
QK modifier — indicates medical direction of 2, 3, or 4 concurrent anesthesia procedures
QK meaningQK modifier indicates medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals and must be appended by the directing anesthesiologist when applicable.
Modifier selectionProviders must determine which modifier most appropriately defines the service and append one appropriate modifier to anesthesia CPT code each time anesthesia is billed.
Reference for modifier instructionsRefer to policy modifier guidelines and Attachment B for additional billing instructions related to anesthesia CPT codes.
AD modifier — indicates medical supervision by a physician for more than 4 concurrent anesthesia procedures
AD meaningAD modifier indicates medical supervision by a physician for more than four concurrent anesthesia procedures and is used by anesthesiologists who provide supervision to more than four CRNA procedures.
Physician billing implicationWhen supervising >4 CRNAs, the anesthesiologist will bill using AD and is reimbursed 45 base units for every procedure being supervised; the anesthesiologist may also bill a one-time 15-minute block if present at induction with documentation.
CRNA modifier interactionWhen AD is used, the CRNA must append QZ to the anesthesia CPT code for services without medical direction.
QS modifier — indicates Monitored Anesthesia Care used with appropriate specialty modifier
QS usageQS modifier indicates Monitored Anesthesia Care (MAC) and must be used in combination with the appropriate specialty modifier (AA, QK, QY for anesthesiologists or QX/QZ for CRNAs).
Append additional modifierWhen MAC is billed, the anesthesiologist must append AA, QK, or QY in addition to QS; the CRNA must append QX or QZ in addition to QS.
MAC presence requirementMAC necessitates continuous actual presence of an anesthesia clinician and includes preanesthetic exam and postoperative care.
Medical direction payment rule — anesthesiologist directs CRNA/AA services and payment is 50% of physician maximum allowed amount
Medical direction payment ruleWhen an anesthesiologist medically directs CRNA or Anesthesiologist Assistant services, physician payment is (Base units + time) x 50% of the physician maximum allowed amount.
Modifiers for directionAnesthesiologist appends QY or QK; CRNA appends QX when medical direction is provided.
Direction requirements tie to paymentBilling for medical direction requires the anesthesiologist to perform specified tasks (pre-anesthesia evaluation, prescribe anesthesia, participate in induction/emergence, monitor frequently, remain physically present, and provide post-anesthesia care).
Medical supervision (>4 CRNAs) — supervision definition and physician reimbursement note (45 base units, possible 15-minute block)
Supervision definition for >4 CRNAsMedical supervision for more than four concurrent CRNAs is indicated by modifier AD; the anesthesiologist is reimbursed 45 base units for every procedure being supervised.
15-minute induction blockAnesthesiologist may bill a one-time 15-minute block of time if documentation shows presence at anesthetic induction.
CRNA billing when supervised >4Under AD supervision, the CRNA appends QZ for services without medical direction per policy instructions.
Anesthesia time reporting — report anesthesia time as minutes where 1 minute = 1 unit; exceptions for some codes
Anesthesia time reporting ruleReport time for all general and monitored anesthesia services as minutes where 1 minute = 1 unit; report actual time in minutes in the units field of CMS-1500.
Codes without recognized time unitsTime units are not recognized for certain codes (e.g., 01967 and 01996); a flat rate of 1 unit per occurrence is allowed for those codes.
Payment uses actual timeMedicaid accepts actual time when billing for anesthesia services and uses actual minutes to calculate time units included in payment formulas.
QZ modifier — indicates CRNA service when CRNA is not medically directed
QZ meaningQZ modifier indicates CRNA service performed without medical direction by a physician and must be appended when applicable; CRNA payment = (Base units + time) x CRNA maximum allowed amount.
Use contextUsed when CRNA performs service without medical direction; providers must append appropriate modifier to the anesthesia CPT code each time anesthesia is billed.
Relation to AD modifierWhen anesthesiologist supervises >4 CRNAs (AD), CRNAs still append QZ for services without medical direction as instructed in policy.
QX modifier — indicates CRNA medically directed by an anesthesiologist
QX meaningQX modifier indicates CRNA service that is medically directed by an anesthesiologist and is appended by the CRNA when medical direction is provided; payment = (Base units + time) x 50% of physician maximum allowed amount for CRNA when medically directed.
Billing relationshipWhen CRNA is medically directed, the anesthesiologist appends QK/QY for direction and the CRNA appends QX for the billed service as applicable.
Payment implicationCRNA payment under medical direction uses 50% of the physician maximum allowed amount in the payment formula per policy.
Policy Summary
PayerAlliance Health (LME-MCO)
PolicyAnesthesia Services
Policy CodePolicy 1L-1
Change TypeMaterial revision (supervision limit updated)
Effective DateOct 1, 2003
Last ReviewAug 15, 2023
Next Review DateN/A
Key ActionAppend the appropriate anesthesia modifier (AA, QY, QK, AD, QZ, QX, QS) for each billed anesthesia service and follow medical direction rules when applicable.
SourceLink
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