Hi, my name is Jeff Molter, CRNA, and I'm here today to talk to you about anesthesia billing and some billing basics. I first wanna say that I am not an attorney and I'm not a billing expert. However, I did own and operate an anesthesia company for several years with three CRNAs and a physician anesthesiologist. So I did have some insight in what went into anesthesia billing. So today I'm hoping to cover these basics and educate you. Our objectives today. First, I wanna talk about the National Provider Identification Number. We as professionals apply for what is known as NPI numbers through the CMS National Plan and Provider Enumeration System. And this is a unique identifier number that follows us throughout our entire career. That when we do an anesthetic on a patient, that NPI number follows that bill and is associated with you as a provider. The anesthesia group that you're working for will have an NPI number. The physician surgeon that you're working with or endoscopist will also have an NPI number. And the facility where you're delivering the anesthetic will also have an NPI number. If you go to this website, you can actually put in your first and last name and do a search and it will tell you what your NPI number is. Every time I provide an anesthetic, my NPI number is going to be tied to that anesthesia bill. So the big question remains, how do you generate revenue as an anesthesia provider? And you can see I listed several things here, but in the world of anesthesia, there's two main ways that we generate anesthesia revenue for whomever we're working for. And that is number one, administering anesthesia. So by administering anesthesia, you are generating revenue. The other thing, the main way, would be by performing blocks or procedures such as epidurals or peripheral nerve blocks. The big thing where we do not generate anesthesia revenue would be the preoperative evaluation. That's an important factor to know. An intubation on the floor or starting an IV with ultrasound. You can bill for those services, but the amount of money that you collect would not be very substantial. The two main ways that we get anesthesia revenue are by administering anesthesia and by performing blocks or procedures such as epidurals. Now, if there's only one thing that you remember from this talk, it is this. We're gonna take base units. To that, we're gonna add time units. And to that, we're gonna add modifier units. We're gonna take that number and multiply it by some specific dollar rate. So that dollar rate is usually a function of the anesthesia group that you work for. In our anesthesia group, our rate was $85 a unit. So we would add those three things together and multiply it times $85, and that would be the patient's anesthesia charge. The base units actually come from the American Society of Anesthesiologists. The time units are 15-minute intervals. Every 15-minute interval is gonna be another unit. So every hour that you're in the operating room, you're gonna generate four time units. Modifier units are things that you can add onto your case. If, for instance, the patient is over age seven, you could add one unit. If it's an emergency procedure, you can add two units. The American Society of Anesthesiologists does come out with this relative value guide every year. This is an old one, the 2018 Relative Value Guide. And what they do is they take procedures and they assign values or base units to these procedures based on the complexity of the procedures. Here we see a list of common procedures and the assigned base units from the ASA Relative Value Guide. And remember, these are just the base units. We're gonna add time units to all of these. So first I wanna talk about how CMS or Medicare defines anesthesia time. So anesthesia time is the time during which a anesthesia provider is present with the patient. Many times our anesthesia time is when the patient rolls in the operating room, we start our anesthesia start time. But I will tell you that you do not count your preoperative exam in your anesthesia time. That is a definite no-no. That is a separate part of anesthesia. That preoperative exam is actually factored into the base unit. Now your anesthesia time is gonna be billed in 15 minute intervals. Your anesthetic is an hour from beginning to end. Then that would be four more units that get added to your base units. Next I wanna talk about anesthesia modifiers. Now these are things that add value to your cases. So for instance, if your patient is under the age of one year old or greater than the age of 70 years old, you can add one unit. If they are a physical status of three, you can add one unit. If it's an emergency, you can add two units. If you're going to be utilizing hypothermia, you can add five units. And if we're gonna be using controlled hypotension, we can add five more units. Now there are other modifiers out there, but these were just three or four or five that I chose as examples. One thing of note, you can add these modifiers to your anesthesia bill, but just know that CMS or Medicare, which is probably the largest insurer or paying customer in the country for anesthesia charges, does not recognize these modifiers. So here I wanna talk about a simple cataract procedure just for an example of what an anesthesia bill looks like. And you're gonna see how very complicated a simple anesthetic could be on a cataract patient. The base units, when you look them up in the relative value guide is four base units. So by initiating or starting this anesthetic on this patient that's having a cataract, we're gonna get paid four base units. Modifiers, let's just say that the patient was 75 years old, we get one modifier. The patient was an ASA3, we get another modifier. So we're gonna add two more units to our bill here. So let's add those up, four base units, two time units, two modifier units. So we're gonna be billing the patient eight units at the rate that our company charges is $85 a unit. So we're gonna bill this cataract patient $680 on their anesthesia bill for this 30-minute cataract procedure. How many of you think we're actually gonna collect $680 on a 30-minute cataract patient? First, I'm gonna start with the private payer, which the majority of our cataract patients are Medicare, but we do occasionally get a private payer in here. But we see this rate here, $52. This is a rate that our anesthesia group agreed to with Medical Mutual of Ohio. We agreed to be in network with Medical Mutual of Ohio. And even though we're charging $85 rate per unit, we will accept $52 as full payment because we are in network. So our bill is 680, but between Medical Mutual of Ohio and this patient, they're gonna owe us $416. And the majority of your cataract patients are gonna be Medicare patients. With Medicare, they are not gonna pay those modifiers. Instead of billing this patient for eight units, we now can only bill them for six units. And on top of that, we're gonna bill them our $85 per unit. And we're gonna send this Medicare patient a bill for $680. But Medicare has a predetermined rate based on the zip code where you're providing the anesthetic. Now in the zip code that I'm at, they pay us a whopping $22 per unit. And we are gonna get paid $132. I also wanted to note that on your Medicare patients, you cannot balance bill them. So that is part of the agreement you make when you accept Medicare as an anesthesia group. So can't get any worse, right? Well, we have a Medicaid plan in the state of Ohio. And Medicaid, just like Medicare, will not pay us for the modifier. So zero modifiers on the same case. Medicaid will pay us $16 a unit, a lot less than Medicare. So on this case that we're gonna bill $680, we are going to collect a whopping $96 from Medicaid. You're not even gonna make enough money to pay for the CRNA or the provider that's in the room giving that anesthetic. I love this slide because it really shows you how with one simple procedure, the amount of money that gets billed and the amount of money that gets collected, if you're ever going to get a contract at a facility and be an anesthesia group, you're gonna wanna know what their payer mix is because that payer mix will determine how much revenue you bring in as an anesthesia group. And next, I wanted to show you a procedure where we make a good amount of money at the facility that I work at when we do shoulder arthroscopies with rotator cuff repairs. The base units here are five. They take on average about three hours from beginning to end to do this procedure. So remember, for every 15-minute interval, we're gonna get a base unit for every 15-minute interval, so a three-hour procedure. We're going to get 12 time units, and then modifier, whether the patient's ASA3, they're over age 70, or it's an emergency rotator cuff repair, we're gonna add on two. We got 17 plus two, 19, times $85. We're gonna be billing this patient and their insurance $1,615 and then we can go right down the line here and see what our private payer would be paying. And at the bottom, we could see if we had this patient was a Medicaid patient, we could expect about $272 for this particular procedure. Now you might ask, what about the blocks? You do make some extra money doing the peripheral nerve blocks when they're ordered for post-operative pain relief. So if you're doing a peripheral nerve block, for example, for our shoulders, we put an inner scalene block in the preoperative area and we have an order from the surgeon that orders this peripheral nerve block for post-operative pain control, and that's very important because you can't just put the block in because you want them to have the block. That would be a self-referral and you may get in trouble for that. So you want to get an order from the physician or the surgeon that they want you to put this block in for post-operative pain control. And you're actually gonna bill for the block that you do and there's gonna be a CPT code assigned to the particular block that you do and you're gonna bill a certain amount for this. And typically, you're gonna get paid a little bit less than half of what you're billing when you're doing these. You'll get paid anywhere from $60 to $92 to do these types of blocks. It is when you do ultrasound guidance, you're going to collect a little bit of additional money. You can see down here that we're billing $516, but I think the amount that you get paid is somewhere around $50. But when you do a preoperative nerve block on a patient, you know, you're gonna collect an extra $100 to $110. Now let's talk about the actual bill that's submitted to Medicare or to the insurance company when an anesthetic is performed. Now this is an actual bill and this is a procedure that I did at our surgery center. And back in those days, before electronic billing submissions, there used to be the CMS-1500 HCFA form. And on this bill or HCFA form would be some essential information. So we have patient demographics. We could see that the patient here has a Blue Cross and Blue Shield insurance. This was an endoscopy procedure that I did on a patient. These are the codes that were given as the reason why the patient needed to have the colonoscopy. Over here, we could see our beginning time and our end time. We could see that our total time was 32 minutes. If we round it up, that would be 15 plus 15 plus two. If we round it up, that would be three time units. And if this colonoscopy was paying five base units, then that would be eight units that we'd be billing this patient at $85 a unit. So the patient's bill would be $680. So this is what an anesthesia bill looks like when it's submitted to insurance. Next, I'm gonna talk about models of anesthesia delivery and how the coding is effective when this happens. Now, when a nurse anesthesiologist or a CRNA is providing an anesthetic non-medically directed, that bill is gonna be given the modifier of QZ when that bill is submitted. And 100% of the payment for that procedure will come in under your NPI number. Now, when a physician anesthesiologist delivers the anesthetic 100% by themselves, the modifier code that's gonna go on that anesthesia bill is the code of AA. And 100% of the money that gets paid will be paid to the NPI number of this physician anesthesiologist. So let's just say there's a solo practice model. And this would be a simple model or example. We have four operating rooms and the care is provided and billed for these providers. And we have four nurse anesthesiologists and they're all billing QZ. And 100% of the payments coming in will be assigned to the NPI number of these nurse anesthesiologists or nurse anesthetists. Now, let's also talk about that same facility, solo practice model, but this time we have four physician anesthesiologists, each providing anesthesia in each operating room. The modifier here now in the billing codes would be changed to AA. Physician anesthesiologists, there's four of them working in four different operating rooms, giving that anesthesia care directly. And 100% of that payment's gonna come in under their NPI numbers. Now, let's talk about medical direction. When you're billing medical direction, then the physician anesthesiologist is medically directing the nurse anesthesiologist. And this modifier code is gonna be QY or QX. So the physician anesthesiologist is medically directing a nurse anesthetist or nurse anesthesiologist. And now when this happens, and let's just say we have one physician anesthesiologist and one CRNA covering one operating room and this physician anesthesiologist is not covering any other operating rooms, 50% of the payment that gets paid for this procedure is gonna go to the NPI number of the physician anesthesiologist and 50% of the payment is gonna go to the nurse anesthesiologist. So for that cataract case that paid $150, $75 is going to go to the physician anesthesiologist NPI number, and $75 is going to go to the nurse anesthesiologist NPI number. In this one-to-one model, it's kind of like, I would like to say, flushing money down the toilet, right? I mean, who in their right mind is going to have two professional anesthesia providers doing one anesthetic on one patient at one time in one operating room? I mean, it seems like a complete waste of money. When medical direction is occurring, there is something known as TEFRA. TEFRA, or the TEFRA rules, were developed by Congress. It's very, very important to know that this is not a standard of care. It is only a requirement of Medicare or CMS when you're billing cases for medical directions. Often, physician anesthesiologists will use these TEFRA guidelines as a quote-unquote standard of care when it benefits them. These TEFRA guidelines went into place back in 1982, and it was part of the Tax Equity and Fiscal Responsibility Act, which is why it's called TEFRA. Now, when a physician anesthesiologist is medically directing one, two, or three CRNAs, they're responsible for doing these things in order to bill medical direction. Number one, prescribing an anesthesia plan. Number two, personally participating in the most demanding procedures of the anesthesia plan. Number three, any procedure not personally performed is performed by a qualified anesthetist. Number four, they need to monitor the course of anesthesia at frequent intervals. Number five, they need to be physically present and available for immediate diagnosis and treatment. And lastly, they need to provide the indicated post-anesthesia care. Remember, these are the TEFRA guidelines when a physician anesthesiologist is medically directing a CRNA. And remember that this is not a standard of care. These are only guidelines developed by Congress for Medicare when physician anesthesiologists are billing medical direction. So let's talk about when a physician anesthesiologist is medically directing two anesthetics at the same time. Now, when this happens, the bill is going to be changed to QK, and the physician anesthesiologist is now going to get 50% of each of these two separate rooms. So in room one, we have a nurse anesthesiologist or nurse anesthetist doing a knee arthroscopy. The nurse anesthetist is going to get 50% of the money that's generated for this case. In room two, a nurse anesthetist or nurse anesthesiologist is doing a shoulder arthroscopy. 50% of the money that gets generated for this procedure is going to get assigned to the NPI number of this nurse anesthetist. Well, this physician anesthesiologist over here, who is medically directing operating room one, operating room two, they're going to get 50% of the revenue generated from room one, and they're also going to get 50% of the money generated from room two. So that would be medical direction in a two-to-one model. Now, a physician anesthesiologist can medically direct up to four CRNAs or four anesthesiologist assistants. And if they are medically directing them, our code gets changed to QK, and now this physician anesthesiologist is going to get 50% of each room here, up to four rooms. So they're essentially bringing in 200%, they're getting 50% of room one, 50% of room two, 50% of room three, 50% of room four. Now, in medical supervision, you'll rarely, rarely see this model because it does not bring in the amount of revenue that it should when physician anesthesiologists are medically supervising four to five rooms. When this happens, the coding gets changed to AD. Each nurse anesthesiologist is going to bring in 50% of the revenue for the case that gets billed. The physician anesthesiologist now, because they're medically supervising, they now can only get paid three units at a maximum for each case here. So they're no longer getting 50% of each case, they're only going to get three units times five different cases at once, so they're going to only be able to bill 15 units, which is not a ton of money. The one thing about billing medical supervision for the physician anesthesiologist though is that they no longer have to meet those TEFRA guidelines. I forgot to mention earlier, when cases are being billed QZ or CRNA non-medically directed, even if there's an anesthesiologist in the building or around or kind of overseeing what you're doing, you do not have to meet the TEFRA guidelines. On the state of Ohio, CRNA Chuck Tabbert came up with this very nice tool that we passed out to all the CRNAs in the state of Ohio and he was showing the differences in billing. He wanted to show the fact in Ohio we have AAs and it's very important that we know that AAs cannot bill QZ, only CRNAs can bill QZ. Again, a non-medically directed CRNA bills QZ, 100% of the revenue will come into the hospital or to the surgery center or to the anesthesia company that is providing those services on behalf of the CRNA. When a physician anesthesiologist does their own case, the modifier is AA and 100% of the money that comes in gets paid under the NPI number of the physician anesthesiologist. Then we see here when we have medical direction involved, when the physician anesthesiologist is directing between one and four CRNAs that the money is split 50-50 between the physician anesthesiologist and the CRNA or it's split 50-50 between the physician anesthesiologist and the AA. Then we could see over here this medical supervision model which is rarely, rarely used because if the procedure is more than six units total, then revenue is potentially lost. Remember because the physician anesthesiologist is only going to get reimbursed three units. And remember these important TEFRA guidelines. These are guidelines established by Medicare that says when a physician anesthesiologist is medically directing a CRNA, they must meet this criteria otherwise billing fraud occurs. Just to remind you, as I said before, remember if you're billing QZ over here, a non-medically directed CRNA, you do not have to worry about the TEFRA rules. These things are all separate and different than your state law or your state requirements. For instance, in the state of Ohio, it is required that CRNAs in the state of Ohio be supervised by a physician. That is in our state law that has nothing to do with this billing terminology. I as a CRNA can still bill QZ that I'm non-medically directed when I'm providing the anesthesia care to the patients. So let me give a couple examples here and how your billing can impact your perceived worth in your facility. So let's just say, and this is an example of our surgery center. We have four operating rooms. They each have a nurse anesthetist or nurse anesthesiologist in there and they're billing QZ and at the end of the year, each CRNA collected about $425,000 in billing revenue. There could be a physician anesthesiologist in the building but these CRNAs can still be working QZ or non-medically directed or you're not billing medically directed. You have a physician anesthesiologist in the building and they're adamant that they medically direct you from a billing standpoint and when they do this, we're going to change over to QK billing and now that the revenue that was generated by the nurse anesthesiologist is the same, however when the money gets broken up and gets paid to the NPI numbers, half of that money that the nurse anesthesiologist generated is going to go to them and the other half is going to go to the NPI number of the physician anesthesiologist. So if the four of these CRNAs in this facility are being medically directed, the amount of billing money that they brought in all gets cut in half and if we have a physician anesthesiologist there, if we had two physician anesthesiologists there and they were medically directing two operating rooms, then they would show, because they're getting 50% of each of those ORs, they're going to show that they brought in $425,000 in revenue under their NPI numbers if they're medically directing two CRNAs in that medical direction model. We change that ratio of one to three. We have one physician anesthesiologist medically directing three of those CRNAs. Remember that half of each of those CRNAs revenue that comes in is going to get assigned to the physician anesthesiologist and at the end of the year, this physician anesthesiologist is going to show that they brought in $637,000 under their NPI number. So they're going to puff out their chest. They're going to say, you're only paying me $450,000 salary and I'm bringing in $637,000. I'm saving you money, man, I'm a great prize for you. Please keep me on board. But this is because half of the money that the CRNAs are generating is going to the NPI number of this medically directing physician anesthesiologist. And on top of that, if the physician anesthesiologist was medically directing all four of those operating rooms, 50% of all those CRNAs revenues would be going to the NPI number of this physician anesthesiologist and this physician anesthesiologist at the end of the year is going to puff out their chest and say, wow, wow, wow, look at me. I billed or brought in $850,000 of revenue and you're only paying me $450,000 a year. I think I need a raise. These CRNAs, they're expensive. I think I need a raise. Look at all this money I brought in. After seeing this presentation, I hope you realize that this is pulling the wool over the eyes of the owners and the people that run the facility, right? Number one, if they weren't medically directing the CRNAs and the CRNAs were billing QZ, this amount of money would still come into the facility. It would just get divided up differently. It'd be divided up in different buckets. This entire amount would be in the NPI numbers of the CRNAs. It wouldn't get divided up. The same amount of revenue would come in. The other thing is, if this physician anesthesiologist is medically directing the four operating rooms, they need to meet those TEFRA guidelines. I'm going to bring that point up because this was a study that was done in their own journals. This was published in Anesthesiology back in 2012 in a study done by Epstein and Dexter and they showed that there were frequent supervision lapses. What they showed in the study that was even at a ratio of two CRNAs to one anesthesiologist, that they had lapses in their TEFRA requirements 35% of the time and that it peaked before 8am. Again, this is just a supervision ratio of one anesthesiologist to two nurse anesthesiologists and they were unable to meet those TEFRA requirements 35% of the time. This was published in their own journal. When the anesthesiologists were asked how to fix this, you think they would say, let's just do away with medical direction and do QZ. What they actually suggested was that you should stagger the start times of the operating rooms so that the physician anesthesiologist could be there at induction or you should hire more physician anesthesiologists at the beginning of the day to reduce these lapses during critical periods. What they're saying is you should hire more of them in order to meet these billing requirements instead of just changing the QZ billing where you don't have to have medical direction, you don't have to follow the TEFRA guideline. Kind of interesting that they put this in their journals. Also want to talk about the American Society of Anesthesiologists. They actually warned their members about QZ modifier. They basically are telling their anesthesiologists that don't let CRNAs bill QZ. And why is that? Well, because it's going to show what their true value is, right? If you have a physician anesthesiologist working at your facility and the only thing that they're doing is preoperative evaluations and they're running pre and post-op orders, none of that is billable revenue. Again, you have to actually be administering an anesthetic or doing a block or doing an epidural in order to have revenue coming into your anesthesia group. Medical direction, again, the half of the money that's brought in comes their NPI number and it appears that they're doing billable work, which they're really not. And if you turn all the billing over to QZ, that means that all the money coming in is going to go to the NPI numbers of those CRNAs performing those anesthetics, but you no longer have to meet those TEFRA guidelines. I could tell you that our facility, I kind of use those numbers and those examples from the facility that I worked at several years ago. And we do have a physician anesthesiologist and she does do pre-op exams and things like that. And we do place her in the operating room to do her own anesthetics. But at the end of the year, the one year I believe she brought in about $59,000 in revenue from actually administering anesthesia, so that gives you an idea. But again, the ASA does not want their members to promote or let CRNAs use this QZ modifier. The other thing they said in this article was that high quality anesthesia care is provided in the United States by physician anesthesiologists or physician anesthesiologists-led anesthesia care teams. So the ASA essentially says that physicians need to be involved in every single anesthetic in this country, which as many of you know, is completely impossible. Now in ending, I want you to remember that that formula that is used in anesthesia billing. We have the base units that come from the ASA relative value guide. Those base units are assigned to a procedure based on the complexity. We're going to add time units to those base units. Those time units come in 15 minute intervals. Every 15 minute interval is an extra unit added on to your bill. Remember that we can add modifiers. Those allow us to add extra units onto our case. Now we're going to multiply the number of units times the rates. Know that the QZ modifier is a non-medically directed CRNA and this comes to anesthesia billing. The QZ modifier means that you're a non-medically directed CRNA when it comes to your billing. Now when medical direction occurs, when the physician anesthesiologist is medically directing up from one to four CRNAs at a time, those tougher guidelines need to be met in order to meet compliance issues. As I said in those last few slides, know that there is a lot of opposition to QZ billing and after seeing this presentation, you could probably see why. And last but not least, CRNAs are part of the solution to escalating healthcare costs.

Jeff Molter

CRNA

anesthesia billing

National Provider Identification Numbers

NPI

base units

ASA