The QZ modifier: Guidelines for anesthesia providers

Editor's note: This article was edited to add clarification from the American Sociey of Anesthesiologists.

The QZ modifier for anesthesia providers has become increasingly complicated as the policy for certified registered nurse anesthetists shifts in many markets, according to a June 10 blog post from Coronis Health 

The definition of the QZ modifier by Medicare is for a CRNA service without medical direction by a physician. According to the report, for Medicare, medical direction is not achieved unless the anesthesiologist meets seven requirements, including performing a pre-anesthetic examination and evaluation, prescribing the anesthesia, providing post-anesthesia care and monitoring the administration at frequent intervals, among others. 

If even one of the requirements is not met, it cannot be deemed medically directed, according to the report. 

"The question then becomes this: since the service cannot be deemed to be medically directed, but a CRNA is present throughout the case, would this not meet Medicare’s definitional threshold of QZ?" the report said, adding that the debate of this question has "raged on for years."

Coronis Health added that the scenario could under the category of medical supervision, an anesthesia-specific term that the CMS describes as a physician service involving more than four concurrent anesthesia providers. Medical supervision is reflected by a different modifier and limits anesthesiologist reimbursements to three base units, plus one time unit if there is documentation that they were present for the induction. However, the report adds, CMS does not define the AD modifier as anything other than involvement with five or more simultaneous cases. 

Additionally, in 2018, a federal district court in California ruled in 2018 that submitting QZ in connection with a case where the anesthesiologist provided some of the elements of medical direction does not constitute a false claim. 

The report added, "virtually all of the Medicare administrative contractors throughout the country have added their seal of approval to the use of QZ where the medical direction requirements were not fully met."

"ASA believes every patient deserves to have their anesthesia care performed or supervised by an anesthesiologist," an ASA spokesperson said in a statement shared with Becker's. "In those circumstances where an anesthesiologist is not available, the anesthesia care must be supervised by the operating surgeon or other physician performing the procedure because that person is the only one, in the absence of an anesthesiologist, with the education and training required for medical decision-making in the operating room and perioperative period."

ASA also clairified that it has no policy statement on the use of QZ when the requirements for medical direction are not met. 

"ASA is concerned that when QZ is used in situations where an anesthesiologist has an active role in providing anesthesia care, that work and the anesthesiologist’s attendant obligation to the patient are obscured by the use of QZ," the statement added. "This is regrettable, as policy makers and the public may draw incorrect conclusions about the prevalence of truly independent practice by nurse anesthetists, which actually represents only a small fraction of anesthesia care in the United States."

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