CRNA and anesthesiologist double billing question

[RogueDadMD]

So at the end of Dec one of our kids had ear tubes placed.  A CRNA did the anesthesia, though we know there was a supervising anesthesiologist floating around (he came to talk to us and we know him).

We received the physician bill today, and we were billed for both.  They used the exact same codes, had the same contractual adjustment, and same insurance payment, so the total to us was the same for each.  The code billed is "AN-69436.00126 Tympanotomy (CREATE EARDR)"

I've no clue what that code means beyond the obvious, and can't find anything about it.

The real question is -- what is the billing arrangement between the MD and CRNA?  I've read that they can each bill 50% of the amount if the MD was supervising, but I can't really tell if that's what happened here, or if they both billed the full amount.  I've seen mention of other billing modifiers such as "AA" and others, but can't find "AN" anywhere.

Before I call and start arguing with the billers at my own home institution about a relatively small bill from someone I know personally (which I have done before and am perfectly willing to do if it's inappropriate billing), figured I should see what the audience thinks.

[PhysicianOnFIRE]

I believe you work at an academic center, in which case neither the anesthesiologist or the CRNA is billing you. They're doing their jobs, collecting a salary, and the billing is handled by the institution or a contracted third party.

In the case of a CRNA being medically directed by an anesthesiologist, the billing is commonly assigned 50 / 50 between the two. You could certainly call and inquire, but if you were "double billed," either everyone is getting billed similarly or you were a rare unlucky case. I'd guess the former.

I'm no expert on billing, though. I'm one of those guys that does his job and collects a salary. Someone in private practice who gets into the weeds on this stuff may have a better answer.

Best,

-PoF

[Hatton]

I have heard complaints about this also. When I have had surgery I have requested MD anesthesia so I have never been double billed.  I imagine the charges are maximized unless you complain loudly

[Ryan]

Try calling your health insurance. If it's anything like mine-- it has an "overbilling" line specifically for these types of questions. Let them sort it out.

[MPMD]

My understanding was the the main anesthesia professional charge was simply a unit of time under anesthesia. So if you're a tough airway and there are 2 attendings and a CRNA in there helping I don't think you get charged more.

From a brief google search it looks like CRNA service is a modifier on a physician code?

[PhysicianOnFIRE]

If you get charged for both providers, the charge should be half from each. If you get charged for only a physician or CRNA, the charge would be full charge.

Some anesthesia groups use a looser "supervision" model rather than a "medical direction" model. The reimbursement is the same, but the latter has more documentation requirements. In the former case, all the billing is attributed to the CRNA only, even though the physician is deeply involved in the patient's care. I believe they use the QZ modifier in this case. Interestingly, that's how one terrible study that showed equivalent outcomes with "CRNA only" anesthesia was done, using the QZ billing modifier, which is often used when a physician is involved in the anesthesia care.

[GasFIRE]

The anesthesia charge is usually composed of two parts, the base and the time units. The base units, determined by the surgical procedure, plus the time units are multiplied by the unit charge to arrive at the total charge. For CRNA supervision, most insurers pay the CRNA 50% and the supervising physician 50%. If the case was done by the physician only, they would get 100%. It’s difficult to impossible to actually decipher this from the insurance bill.

[Craigy]

Rogue Dad, M.D. wrote:

So at the end of Dec one of our kids had ear tubes placed.  A CRNA did the anesthesia, though we know there was a supervising anesthesiologist floating around (he came to talk to us and we know him).

 

Click to expand...

Did the CRNA really do the anesthesia?  Usually CRNA just sits the case.

[Zaphod]

Craigy wrote:

Rogue Dad, M.D. wrote:

So at the end of Dec one of our kids had ear tubes placed.  A CRNA did the anesthesia, though we know there was a supervising anesthesiologist floating around (he came to talk to us and we know him).

 

Click to expand…

Did the CRNA really do the anesthesia?  Usually CRNA just sits the case.

Click to expand...

Usually depends on location. Some places, like California, CRNA practice independently even.

[Craigy]

Zaphod wrote:

Craigy wrote:

Rogue Dad, M.D. wrote:

So at the end of Dec one of our kids had ear tubes placed.  A CRNA did the anesthesia, though we know there was a supervising anesthesiologist floating around (he came to talk to us and we know him).

 

Click to expand…

Did the CRNA really do the anesthesia?  Usually CRNA just sits the case.

Click to expand…

Usually depends on location. Some places, like California, CRNA practice independently even.

Click to expand...

8O   Nuts!!

[Wiscoblue]

Thankfully, there are no CRNAs in my town. But our ER and hospitalist dept is full of midlevels. And many patients go through ER and are admitted without ever having seen a real doctor. In the case of an ankle fracture being treated by a podiatrist, the anesthesiologist might be the only doc to have contact with an elderly lady with CHF and valvular heart disease.

[Hatton]

I have worked with lots of CRNAs supervised by anesthesiologists.  With routine not sick patients they are great.  CRNAs are well trained and really work hard in my hospital.

[GasFIRE]

PhysicianOnFIRE wrote:

If you get charged for both providers, the charge should be half from each. If you get charged for only a physician or CRNA, the charge would be full charge.

Some anesthesia groups use a looser “supervision” model rather than a “medical direction” model. The reimbursement is the same, but the latter has more documentation requirements. In the former case, all the billing is attributed to the CRNA only, even though the physician is deeply involved in the patient’s care. I believe they use the QZ modifier in this case. Interestingly, that’s how one terrible study that showed equivalent outcomes with “CRNA only” anesthesia was done, using the QZ billing modifier, which is often used when a physician is involved in the anesthesia care.

Click to expand...

The QZ modifier is supposed to be used for CRNA cases performed without medical direction by a physician. For cases that are medically directed by an anesthesiologist CMS has a list of 7 steps that are supposed to be performed/documented. If the anesthetic record is missing any of these parts, you risk a denial of payment. So unless the medically directed documentation is pristine, many groups will default to billing the case using the QZ modifier to improve chances of prompt payment. Basically a billing game that as noted does erroneously inflate the number independently performed vs medically directed CRNA cases.

[RogueDadMD]

Wasn’t trying to start a CRNA bashing session here!

Yes, I am in an academic center with people that only do peds and who are salaried. I know they have billers and coders, but I hope they aren’t fraudulently full double billing for every case. My institution is very risk averse so don’t suspect off hand intentionally overbilling.

Anesthesia for this is so simple it frankly doesn’t matter to me who does it — it’s all mask anesthesia and is only a few minutes.

If the bill represents a 50-50 split that’s fine — I assume the CRNA did it, but the MD may have “supervised” or popped his head in. No way for me to know and I wasn’t there to ask.

I’ll probably call to inquire.

[PhysicianOnFIRE]

Rogue Dad, M.D. wrote:

Anesthesia for this is so simple it frankly doesn’t matter to me who does it — it’s all mask anesthesia and is only a few minutes.

Click to expand...

There are times where it absolutely does matter. You should be thankful that an anesthesiologist was involved and almost certainly in the room when your child was induced.

Airway obstruction is common upon induction and emergence and a few minutes of apnea can be devastating to a young child's brain. I'm not saying an anesthetist can't recognize or treat an airway obstruction, but I've been the second pair of hands more than a few times for kids with laryngospasm in cases as simple as ear tubes.