5101:3-8-25 Coverage, limitations, and reimbursement of anesthesia services provided by certified registered nurse anesthesists (CRNAs.).

(A) The department will reimburse a CRNA for general, regional or supplementation of local anesthesia services (monitored anesthesia care as described in paragraph (I) of rules 5101:3-4-21 of the Administrative Code) provided during a surgical or diagnostic procedure. Anesthesia services include the basic preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the usual monitoring procedures. Anesthesia services include ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry as usual monitoring procedures. Unusual monitoring procedures (e.g., intra-arterial, central venous and swan-ganz) are not included and may be separately billed and reimbursed as long as the performance of these services are not limited by Ohio law.

(B) A CRNA is considered to be self-employed if the CRNA is in a solo practice and the practice is free of the fiscal, administrative, and professional control of a CRNA group practice, an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider type.

(C) An independent CRNA group practice is a practice composed solely of two or more CRNAS enrolled under the medicaid program and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider.

(D) Reimbursement for anesthesia services provided by a CRNA may be made directly to a CRNA provider type only if the services were provided by a self-employed CRNA or by a CRNA employed by an independent CRNA group practice.

(E) A CRNA's provider number may be listed on a medicaid invoice under the following circumstances only:

(1) When a claim is being submitted for anesthesia services provided by a CRNA who either is self-employed or a member of an independent CRNA group practice;

(2) When a crossover ("F-type") claim is being submitted, in accordance with paragraph (G)(2) of this rule, for medicare co-insurance and deductible payments;

(3) When a claim is being submitted, in accordance with paragraph (H)(2) of this rule, for anesthesia services that were provided by a non-medically directed physician-employed CRNA; or

(4) When a claim is being submitted in accordance with paragraph (H)(1) of this rule, for anesthesia services that were provided by a medically-directed or medically-supervised physician-employed CRNA.

(F) A CRNA is considered to be:

(1) "Medically directed" if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code;

(2) "Nonmedically directed" if anesthesia services are provided without a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code; and

(3) "Medically supervised" if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) (4) of rule 5101:3-4-21 of the Administrative Code.

(G) Separate reimbursement will be made for the medicare coinsurance and deductible amounts due for medicare covered CRNA services provided to a patient who is dually eligible for medicare and medicaid, even if direct reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g, hospital-employed CRNA services, physician-employed CRNA services, etc.).

(1) The co-insurance and deductible payments should normally be made through the automatic crossover mechanism.

(2) If the claims did not get paid through the automatic crossover mechanism, the provider must submit a medicaid crossover "F-type 6780" claim, in accordance with the crossover billing instructions except that the CRNA's provider number must be submitted as the rendering provider and the employing provider number must be submitted as the pay to provider.

(H) The following CRNA reimbursement policies apply when services are provided to medicaid patients who are not also covered under medicare.

(1) Reimbursement of anesthesia services provided by a medically directed or medically supervised physician-employed CRNA.

When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was provided by a physician in the practice, reimbursement for the services of the CRNA and the directing physician is paid to the employing physician or physician group practice as described in paragraph (H)(3)(b)(ii) of rule 5101:3-4-21 of the Administrative Code. For reimbursement, the physician who provided the medical direction would be listed as the rendering provider and the appropriate modifier indicating medical direction listed in paragraph (D)(1) of rule 5101:3-4-21 of the Administrative Code must be billed.

(2) Reimbursement of anesthesia services provided by a non-medically directed and non-medically supervised physician-employed CRNA.

(a) When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was not provided by a physician in the practice, reimbursement for the services of the CRNA is reimbursable only to the employing physician or physician group practice.

(b) For reimbursement:

(i) The provider number of the employing individual physician practice or the employing physician group practice must be listed in the group practice space on the invoice;

(ii) The provider number of the CRNA must be listed in the rendering provider space on the invoice; and

(iii) The appropriate anesthesia code must be modified with the QZ modifier.

(3) Reimbursement of anesthesia services provided by hospital-employed CRNAs.

Direct reimbursement is not available for anesthesia services provided by a hospital employed CRNA. The reimbursement for the services provided by the CRNA is bundled into the facility payment made to the hospital. When a physician provides medical direction to a CRNA who is employed by the hospital, only the physician who provided the medical direction to the CRNA is entitled to reimbursement on a fee-for-service basis.

(4) Reimbursement of anesthesia services provided by self-employed CRNAs or CRNAs who are members of an independent CRNA group practice.

(a) Direct reimbursement for anesthesia services provided by a self-employed CRNA or a CRNA who is a member of an independent CRNA group practice is available whether or not the CRNA is medically directed by a physician.

(b) When a physician provides medical direction or medical supervision to a CRNA who is self-employed or a member of an independent CRNA group practice, reimbursement for the medical direction of the CRNA is also available to the physician and must be billed in accordance with rule 5101:3-4-21 of the Administrative Code.

(c) Reimbursement is not available for supervision services provided by a physician when the physician does not meet the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code.

(d) The CRNA or CRNA group practice must bill the code for the appropriate anesthesia code modified by either the QX or QZ modifier and report the total anesthesia time in minutes.

(i) If the CRNA was medically directed or medically supervised, the procedure code must be modified with the QX modifier.

(ii) If the CRNA was not medically directed, the procedure code must be modified with the QZ modifier.

(e) The policies contained in paragraphs (B), (D)(3), (E), (F) and (G) of rule 5101:3-4-21 of the Administrative Code also apply when anesthesia services are provided and billed by CRNAs.

(I) When a CRNA provides supervision and personal direction to a student nurse anesthetist involved in the provision of anesthesia services, reimbursement for the services of the CRNA is available in accordance with paragraph (G) of this rule. Reimbursement for the services of the student nurse anesthetist is bundled into the reimbursement made to the facility or hospital.

Effective: 09/01/2005
R.C. 119.032 review dates: 06/06/2005 and 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 3/30/95, 5/1/01