General Information

2. General Information • A Certified Registered Nurse Anesthetist (CRNA) is a registered nurse who has completed additional training in anesthesia. The Medicare program recognizes separate payment for anesthesia services and related care services furnished by the CRNA. This could be a hospital, physician or ambulatory surgical centers (ASC). CRNA anesthesia services are subject to the usual Part B coinsurance and deductible, and payment for CRNA services is made only on an assignment basis. MCPM CH 12. (Pub 100-04, C12, S140.3.4) • CRNAs provide anesthesia for a wide variety of surgical cases and are the sole anesthesia providers in most rural hospitals. The over 30,000 CRNAs in the U.S. work in every setting in which anesthesia is delivered including hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers (ASCs), pain management units and the offices of dentists, podiatrists and plastic surgeons.

3. Qualifications for Certified Registered Nurse Anesthetist (CRNA) • A Certified Registered Nurse Anesthetist is a registered nurse who is licensed by the state in which the nurse practices and who: • Is currently certified by the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists, or • Has graduated within the past 18 months from a nurse anesthesia program that meets the standards of the Council of Accreditation of Nurse Anesthesia Educational Programs and is awaiting initial certification MCPM CH 12 Pub 100-04, C12, S140 & S140.2

4. Covered Services • Payment for the services of a CRNA may be made to the CRNA who furnished the anesthesia services or to a hospital, an Ambulatory Surgical Center (ASC), or a physician with which the CRNA has an employment or contractual relationship. • MCPM CH 12 • Pub 100-04, C12, S140.3.4

5. Services Otherwise Excluded From Coverage • CRNA services may not be covered if they are otherwise excluded from Medicare coverage even though a CRNA may be authorized by state law to perform them. • Payment can be made for medical or surgical services furnished by non medically directed CRNAs if they are allowed to furnish these services under state law. These services may include the insertion of Swan Ganz catheters, central venous pressure lines, pain management, emergency intubations, and the pre-anesthetic examination and evaluation of a patient who does not undergo surgery. Payment is determined under the physician fee schedule on the basis of the national physician fee schedule conversion factor, the geographic adjustment factor, and the resource-based relative value units for the medical or surgical service. • MCPM CH 12 • Pub 100-04, C12, S50

6. Payment for Services of a Certified Registered Nurse Anesthetist • The anesthesia service of the CRNA may be furnished under the medical direction of a physician or without medical direction. The physician, usually an anesthesiologist, who medically directs up to four concurrent anesthesia procedures, can be paid for the physician medical direction service. In addition, the anesthesia service furnished by the medically directed CRNA can be paid. The allowance for both the physician medical direction service and the service of the medically directed CRNA is equal to 50 percent of the allowance otherwise recognized had the service been furnished by the anesthesiologist alone.

7. Certified Registered Nurse Anesthetist Billing Modifiers • The following modifiers are used by CRNAs when billing for anesthesia services: • QS - Monitored anesthesiology care services (can be billed by a CRNA or a physician). • QX - CRNA with medical direction by a physician. • QZ - CRNA without medical direction by a physician • MCPM CH 12 .(Pub 100-04, C12, S140.3.3)

8. General Billing Instructions • Claims for reimbursement for CRNA services should be completed in accordance with existing billing instructions for anesthesiologists with the following additions: • All claim forms must include the following certification, as applicable “CRNA services have been medically directed” (indicate “A” in field 41, location l05 of Claim Detail l on an EMC bill), or; “CRNA services have not been medically directed” (indicate “B” in field 41, location l05 of Claim Detail l on an EMC bill) • If an employer-physician furnishes concurrent medical direction for a procedure involving CRNAs and the medical direction service is unassigned, the physician should bill on an assigned basis on a separate claim for the CRNA service. If the physician is participating or takes assignment, both services should be billed on one claim but as separate line items.

9. General Billing Instructions Cont’d • All claims forms must have the provider billing number of the CRNA and/or the employer of the CRNA performing the service in either block 24.H of the Form CMS-1500 and/or block 31 as applicable. Verify that the billing number is valid before making payment. Payments should be calculated in accordance with Medicare payment rules in §140.3. Carriers must institute all necessary payment edits to assure that duplicate payments are not made to physicians for CRNA services or to a CRNA directly for bills submitted on their behalf by qualified billers. CRNAs are identified on the provider file by specialty code 43. • MCPM CH 12 • Pub 100-04, C12, S140.3.4

10. Anesthesia Time and Calculation of Anesthesia Time Units • Anesthesia time means the time during which a CRNA is present with the patient. It starts when the CRNA begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the CRNA is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. • Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished on or after January 1, 2000, the CRNA can add blocks of time around an interruption in anesthesia time as long as the CRNA is furnishing continuous anesthesia care within the time periods around the interruption. • MCPM CH 12 • Pub 100-04, C12, S140.3.2

11. Next Steps For Navigating This Course • You may choose to view any section of the presentation (CRNA, PA, NP, CNM, CNS, Additional Information) by clicking on the menu selections at the beginning of this set of Power Point slides. • You may close out of this course by clicking on the ‘x’ in the top right hand corner of your browser. • This course contains hyperlinks that appear in underlined blue text and a hyperlinkis a word or graphic that takes the viewer to a web page. Use the left button of your mouse to click on the hyperlink. It automatically links you to a new window that will open on top of the current window. You will not loose your place in the course. To close the window and return to the course click on the ’x’ in the upper right hand corner of your browser. • To print a the page that you are viewing click on ‘File’ at the top of your browser and then click ‘Print’ for the drop down menu. If you cannot access the ‘File’ menu right click using your mouse and select ‘Print’ from there. • For more information regarding any of the following topics click on the Additional Information section. When you reach the Additional Information section you have the option to select one of the following topics: • Home Care Visits Codes • Care Plan Oversight • Correct Coding Initiative (CCI) • Enrollment • Downloads and Links • RHC & FQHC • Reimbursement • Evaluation and Management • Service Codes • Consultation Service Codes • Non Physician Practitioner Incident To • Specific Coverage Criteria • Institutional Setting • Noninstitutional Setting • Nursing Facility Services