GI Endoscopy cases present a unique challenge for an anesthesiologist or anesthesia provider that works in a care team environment. Due to the short duration of these cases and the multiple rooms being covered, it is not always possible to meet the TEFRA requirements for medical direction. Especially problematic is the requirement of being present at emergence on these procedures.
By definition, GI endoscopy cases using Propofol are general anesthetics, since the patient loses consciousness and the ability to respond purposefully during the case. Anesthesia groups cannot skirt the “emergence” requirement simply by calling such cases “MACs”, or Monitored Anesthesia Care.
To address this compliance concern, some groups have begun considering designating their GI locations as “collaborative” sites. The term “collaborative” infers that the anesthesia practice employs their nurse anesthetists and is electing to bill under the CRNA’s name in cases which involve clinical oversight by an anesthesiologist. This approach has been endorsed by most insurance plans, including many Medicare carriers. Claims are submitted under the CRNA using the “non-medical direction” –QZ modifier, and payment per case is typically revenue neutral, without the onerous requirement of meeting the 7 clinical steps of medical direction. However, this solution only works if a group employs their CRNAs, since there is no billable service for the anesthesiologist when employing this methodology.
As an alternative for groups that do not employ their CRNAs, practices can also elect to designate their GI locations as “medically supervised” sites. Under this model, anesthesiologists bill using the “medical supervision” –AD modifier. Similar to the collaborative model, medical direction requirements do not apply and payment to the anesthesiologist is typically revenue neutral. The supervising anesthesiologist is however, expected to be immediately available to all nurse anesthetist rooms being covered, and dedicated solely to the GI suite.
Groups should carefully consider any modifications to their existing practice, and should consult with legal counsel to determine which clinical model is best suited for them.