1. (a) This subsection applies to certified registered nurse anesthetists (CRNAs) and certified anesthesiologist assistants (AAs). The term “qualified non-physician anesthetist” refers to both CRNAs and AAs.
2. (b) The maximum fee for anesthesia services furnished by qualified non-physician anesthetists is the fee determined by this section and section 9789.18.1.
3. (c) Anesthesia time means the time during which a qualified non-physician anesthetist is present with the patient. It starts when the qualified non-physician anesthetist begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the qualified non-physician anesthetist 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, the qualified non-physician anesthetist can add blocks of time around an interruption in anesthesia time as long as the qualified non-physician anesthetist is furnishing continuous anesthesia care within the time periods around the interruption.

4. (d) The following modifiers are used when billing for anesthesia services:

   1. (1) QX -- Qualified non-physician anesthetist with medical direction by a physician.
   2. (2) QZ -- CRNA without medical direction by a physician.
   3. (3) QS -- Monitored anesthesiology care services (can be billed by a qualified non-physician anesthetist or a physician).
   4. (4) QY -- Medical direction of one qualified non-physician anesthetist by an anesthesiologist.

5. (e) Where a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed qualified non-physician anesthetist, the payment amount for the service of each is 50 percent of the allowance otherwise recognized had the service been furnished by the anesthesiologist alone. The modifier to be used for current procedure identification is QX.

   1. (1) For the single medically directed service, the physician will use the modifier “QY” (Medical Direction Of One Qualified Non-physician Anesthetist By An Anesthesiologist).
   2. (2) For the anesthesia service furnished by the medically directed qualified non-physician anesthetist, the qualified non-physician anesthetist will use the current modifier “QX.”

   3. (3) In unusual circumstances when it is medically necessary for both the qualified non-physician anesthetist and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report using the “AA” modifier and the qualified non-physician anesthetist would use “QZ,” or the modifier for a nonmedically directed case.

      Documentation must be submitted by each physician and qualified non-physician practitioner to support payment of the full fee.

   Where the qualified non-physician anesthetist and the anesthesiologist are involved in a single anesthesia case, and the physician is performing medical direction, the service is billed in accordance with the following procedures:

6. (f) Payment can be made to a teaching CRNA who supervises a single case involving a student nurse anesthetist where the CRNA is continuously present. The CRNA reports the service using the usual “QZ” modifier. This modifier designates that the teaching CRNA is not medically directed by an anesthesiologist. No payment shall be made for the service provided by a student nurse anesthetist.

7. (g) The teaching CRNA, not under the medical direction of a physician, can be paid for his/her involvement in each of two concurrent cases with student nurse anesthetists. Payment is allowed at the regular fee schedule rate if the teaching CRNA is involved with two concurrent student nurse anesthetist cases. The CRNA reports the anesthesia service using the “QZ” modifier.

   To bill the anesthesia base units, the CRNA must be present with the student nurse anesthetist during the pre and post anesthesia care for each of the two cases.

   To bill anesthesia time for each case, the teaching CRNA must continue to devote his/her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient's health status and other factors.

   The teaching CRNA must document his/her involvement in the cases with the student nurse anesthetists.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

History

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).