Modifiers are two-character suffixes either alpha or
numeric. A modifier can also have both alpha and numeric values that are
attached to a procedure code. CPT modifiers are defined by the American Medical
Association (AMA). While HCPCS Level II modifiers are defined by the Centers
for Medicare and Medicaid Services (CMS).
Like CPT codes, the use of modifiers also requires explicit
understanding of different things including the purpose of each modifier. With the help of
Modifiers, a change in procedure can be
showed. In other words, Modifier
actually indicates that the service or procedure has been altered by some
specific circumstance, but there is no change in definition or code.
Use of modifier is not limited. More than one modifier can
also be attached to a procedure code if applicable. People usually misunderstand that all
modifiers can be used with all procedure codes but this is not the case. In addition
to this, there is another misconception about Modifiers that they can be used to report services that are
"similar" or "closely related" to a procedure code. This is
also wrong, modifiers are not intended to do so.
Before I explain the QZ Modifier, I would like to give a
brief explanation of Anesthesia, as these Modifiers have direct link to it.
Most of us know that what an Anesthesia is, and if you don’t know then it is
the administration of a drug or anesthetic agent by an anesthesiologist or Certified
Registered Nurse Anesthetist, also known as CRNA.
It is used for medical or surgical purposes in order to
relieve pain. This is not the only purpose of Anesthesia but it is also used to induce partial or
total loss of sensation or consciousness during a procedure, this function of
Anesthesia is known as its primary function.
In addition to Anesthesia, there is also supervised
Anesthesia. When a physician will provide medical direction and oversight for a
qualified anesthetist (CRNA) or a student performing anesthesia services, is
known as supervised Anesthesia. The physician may supervise a CRNA, resident,
or student nurse anesthetist in a single anesthesia case.
Besides this a physician may be medically directing 2, 3, or
4 concurrent procedures. In such case, specific modifiers exist to designate
the medical direction provided, the number of cases which are supervised, and
whether or not the CRNA services were performed under the supervision and
medical direction of a physician.
Codes and Definitions
So now is the Modifier turn, MDA(QK/QY) and CRNA(QX/QZ). Firstly
MDA modifiers , i.e. QK/QY
- Modifier QK Medical
direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals
- Modifier QY Medical direction of one certified registered
nurse anesthetist (CRNA) by an anesthesiologist
- Modifier QX is used
for CRNA service which is there with medical direction by a physician
- Modifier QZ is used for
CRNA service which is there without medical direction by a physician
Reimbursement Guidelines for QZ Modifier MDA(QK/QY) and
According to Medicare, the Coding Guidelines are:
“The Part B
Contractor determines payment for the physician’s medical direction service
on or after January 1, 1998, on the basis of 50 percent of
the allowance for the service performed
by the physician alone.”
While as per
Reimbursement Guidelines, the physician
and the CRNA should use the appropriate modifiers to indicate the medical direction
of anesthesia or supervised anesthesia services provided.
All Services that are submitted with modifiers QK, QX, and
QY will be reimbursed at 50% of the applicable fee schedule rate. It is so
because the supervision/services was shared between two providers.
In case of two anesthesia services claims for the same
patient, same date of service, and no
medical direction/supervision modifiers are appended, only the first claim processed will be
While the second
claim processed is subject to denial as services furnished by another provider.
There is no adjustment for reimbursement to the second
anesthesia provider. It will not be processed until a corrected claim is received from the
first anesthesia provider with the missing QK, QX, or QY modifier appended. The billing office for the denied claim
is responsible to contact the billing office for the other anesthesia provider involved.
It is essential to use proper modifiers attached to the
anesthesia codes while Claiming for
supervision of residents and student nurse anesthetist .An MDA filing a claim for medical direction of a CRNA must
meet all of the seven Medical Direction criteria as required by CMS. The MDA
- Perform a pre-anesthetic
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 that he or she does not perform are performed by a qualified
- Monitor the course of anesthesia
administration at frequent intervals;
- Remain physically present and
available for immediate diagnosis and treatment of emergencies;
- All claims for anesthesia
services must be billed on a 1500 claim form.
- The actual number of anesthesia
minutes will be reported as the number of units. The payment modifiers (AA, QY,
QK, QZ & QX) must be in the first modifier position on the claim.
- Claims submitted without a
payment modifier will be returned to the provider.
- When both a CRNA and an MDA claim
using these modifiers are received for a single anesthesia case, WSI will
request documentation to support payment of the full fee for both providers.