Indiana Health Care Programs (IHCP) will no longer reimburse claims that include medical direction by an anesthesiologist of a single anesthesia session with a certified registered nurse anesthetist (CRNA) or anesthesiologist’s assistant (AA). The recent announcement by IHCP brings Indiana Medicaid reimbursement in line with existing medical policy which prohibits paying medical direction in this instance.
According to Indiana Administrative Law, in those cases where an anesthesiologist is supervising a single CRNA or AA, the procedures performed during the session are considered personally performed by the anesthesiologist and should be billed by her only using modifier AA. The law does allow for exceptions, however. If the involvement of both the anesthesiologist and the anesthetist was medically necessary, providers can submit documentation to Indiana Medicaid with the claims, and reimbursement may be made for the services of each practitioner.
Indiana Medicaid will reimburse for medical direction when an anesthesiologist medically directs two, three, or four concurrent procedures involving qualified anesthetists. In these cases, all procedures would be submitted with the physician’s NPI number, a modifier QK indicating the physician’s oversight, and modifier QX indicating the anesthetist’s work. The physician would be paid 30 percent of the total Medicaid allowed amount, and the anesthetist would be paid 60 percent.
For medical direction to take place, the anesthesiologist must do the following:
- Ensure that only qualified individuals administer the anesthesia.
- Monitor anesthesia at frequent intervals.
- Participate in the most demanding portions of the procedures, including induction and emergence, if applicable.
- Perform the preoperative evaluation.
- Perform the postoperative evaluation.
- Prescribe an anesthesia plan.
- Remain immediately available and do not perform other services concurrently
Here’s a brief chart indicating how medical direction should be billed to Indiana Medicaid:
| 1 Case | 2-4 Cases | |
| NPI Used | Physician’s | Physician’s |
| Physician Modifier | AA | QK |
| Physician Payment | 100% of allowed amount | 30% of allowed amount |
| CRNA/AA Modifier | NONE | QX |
| CRNA/AA Payment | NONE | 60% of allowed amount |
For more information about billing Indiana Medicaid for medical direction, review the following documents:
- IHCP’s announcement about enforcing current medical policy
- Indiana Medicaid Anesthesia Services Provider Reference Module
- Indiana Administrative Code Article 5 (see page 22)
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