When filing claims through the Medicare program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are revenue neutral - meaning reimbursement is equal to the same amount. For example, when medical direction modifiers “QK and QX” are reported (see table below), reimbursement is divided equally (50% and 50%) between the physician and the CRNA. When a CRNA is non-medically directed, full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems. Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!
Many private insurers expect CRNA services to be billed under the anesthesiologist, on one line of the claim form. Reporting separately may result in a claim denial or improper payment. An additional confusion, since many practices generally equally split the full amount of the bill between the physician and CRNA, is that the claim is viewed as a duplicate. Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.
One way to avoid confusion when you must bill two claims, i.e. to collect a Medicare secondary balance, is to charge different amounts for the physician and CRNA. For example, in our practice we assigned 70% of the conversion factor to the physician and 30% to the CRNA; however, your practice may choose to assign a different value. Assigning different values when claims must be split helps identify and separate the services of the physician and the CRNA, as well as decrease odds the claims will be mistaken as duplicate. It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!
How can you tell when to send separate claims? One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNAs. To receive payment from carriers that require two claims, the CRNA must have a valid provider number and have reassigned their benefits. It is important to ensure the provider number is valid before the CRNA begins working. Many practices lose revenue by their inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA whose number is not yet in place, such as temporary providers. Although short-term contract or temporary CRNAs are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.
In most instances, CRNAs are prohibited from using the Q6 modifier to receive payment, since by definition the modifier indicates the service was provided by a “physician.” However, as to be expected in the anesthesia world of billing, there are no “absolutes”! Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6 modifier by CRNAs. Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.