Effective March 12, 2023, Cigna will reduce payment on services reported with modifier QZ by 15%. Modifier QZ identifies services provided by CRNAs without medical direction of a physician. According to Cigna, this was done to align payment with other advanced practice providers (e.g., nurse practitioners). Cigna will only implement this policy change on its commercial lines of business but not on its Medicare Advantage or Medicaid Managed Care lines of business.

At this point, it is hard to determine the impact of this payment cut on business models that anesthesia practices are using. ASA will be monitoring the long-term implications of this policy change on anesthesia practices.

This policy change makes it important for you to have a clearer understanding of what is considered medical direction versus what is considered medical supervision and the billing modifiers that are associated with them. In order to qualify for medically directed service payment, the anesthesiologist who medically directs CRNAs or certified anesthesiologist assistants (CAAs) in two, three, or four concurrent cases must perform all of the following activities (asamonitor.pub/3lmOWAp):

  • Perform a preanesthetic examination and evaluation
  • Prescribe the anesthesia plan
  • Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence
  • Ensure that any procedures in the anesthesia plan they do not perform are performed by a qualified individual
  • Monitor the course of anesthesia administration at frequent intervals
  • Remain physically present and available for immediate diagnosis and treatment ofemergencies
  • Provide indicated postanesthesia care

The anesthesiologist must document in the medical record that they performed the preanestheticexamination and evaluation, the postanesthesia care, and were present during some portion of the anesthesia monitoring and during the most demanding procedures in the anesthesia plan, including induction and emergence, where indicated. If the service meets all these requirements, it is reported using modifier QK. Medicare pays 100% of the allowed amount for medically directed services with 50% of the payment issued to the physician anesthesiologist and the other 50% to the CRNA or CAA.

If the anesthesiologist happens to supervise more than four concurrent cases, it is no longer considered medical direction, but medical supervision, and it would be reported using modifier AD. Medicare only pays three value units per procedure for services reported with modifier AD to the anesthesiologist who supervised more than four concurrent cases. However, an additional time unit may be allowed if the anesthesiologist was present at induction and provides documentation. You might also want to note that Medicare does not allow the supervision of CAAs. CAAs always must work under the medical direction of physicians. Furthermore, private payers and your state’s Medicaid policies might be different.