QZ billing

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RedandBlack7

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Can anyone discuss how QZ billing works and the liability ramifications? The CRNA is practicing independently I believe but as the anesthesiologist in the hospital you are still liable?
 
QZ means your are supervising the CRNA and not Medically directing him/her. The liability is the same as Medical Direction but the billing is different.
If you have a legal arrangement with the CRNA where you have No role in the care of the patient whatsoever then perhaps, the liability will be just on the CRNA. However, in the USA the vast majority of QZ billing simply means TEFRA isn't being met or the ratios are greater than 1:4. This does not change or affect the legal liability to the anesthesiologist. You are still liable and the deep pocket as the supervising physician.
 
BLADEMDA said:
QZ means your are supervising the CRNA and not Medically directing him/her. The liability is the same as Medical Direction but the billing is different.
If you have a legal arrangement with the CRNA where you have No role in the care of the patient whatsoever then perhaps, the liability will be just on the CRNA. However, in the USA the vast majority of QZ billing simply means TEFRA isn't being met or the ratios are greater than 1:4. This does not change or affect the legal liability to the anesthesiologist. You are still liable and the deep pocket as the supervising physician.
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This.
 
BLADEMDA said:
QZ means your are supervising the CRNA and not Medically directing him/her. The liability is the same as Medical Direction but the billing is different.
If you have a legal arrangement with the CRNA where you have No role in the care of the patient whatsoever then perhaps, the liability will be just on the CRNA. However, in the USA the vast majority of QZ billing simply means TEFRA isn't being met or the ratios are greater than 1:4. This does not change or affect the legal liability to the anesthesiologist. You are still liable and the deep pocket as the supervising physician.
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Oh no you said supervising, maybe a douchebag resident should assume you meant something else and presume to ‘correct’ you.
 
Would anyone here ever tolerate a QZ supervision set-up, especially at a busy high acuity practice?
 
As Blade noted, the only reason to bill QZ would be if you were >4:1, or letting CRNAs basically do their own thing. I probably would not take a job like this but if I did I would need a huge salary. A co-resident of mine took a job at a system that I believe was set up like this and he was making serious money, like 800 I believe.
 
RedandBlack7 said:
Would anyone here ever tolerate a QZ supervision set-up, especially at a busy high acuity practice?
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My hospital I trained at did this for all the crnas. QZ across the board. Medical bylaws required medical direction, but I think it's a convenience factor when it comes to less boxes to check.
 
BLADEMDA said:
QZ means your are supervising the CRNA and not Medically directing him/her. The liability is the same as Medical Direction but the billing is different.
If you have a legal arrangement with the CRNA where you have No role in the care of the patient whatsoever then perhaps, the liability will be just on the CRNA. However, in the USA the vast majority of QZ billing simply means TEFRA isn't being met or the ratios are greater than 1:4. This does not change or affect the legal liability to the anesthesiologist. You are still liable and the deep pocket as the supervising physician.
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QZ is "independent" CRNA anesthesia. AD is used when not meeting the TEFRA steps or directing more than 4 CRNAs.

I put "independent" in quotes because many practices are fraudulently billing QZ even though anesthesiologists are involved in the care of the patient, and they do so because QZ probably collects more (in total) than AD. I think insurance companies are getting wise to the QZ scheme, though, and are reimbursing less.


Screenshot 2023-09-28 at 5.40.38 PM.png
 
vector2 said:
QZ is "independent" CRNA anesthesia. AD is used when not meeting the TEFRA steps or directing more than 4 CRNAs.

I put "independent" in quotes because many practices are fraudulently billing QZ even though anesthesiologists are involved in the care of the patient, and they do so because QZ probably collects more (in total) than AD. I think insurance companies are getting wise to the QZ scheme, though, and are reimbursing less.


View attachment 377233
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Agree. But to emphasize, "Supervision" or "independence" for billing purposes is something completely separate of "supervision" and "independent" for medicolegal issues.
 

To test the hypothesis that modifier QZ represents solo nurse anesthetist care, the investigators examined claims from 538 hospitals where every anesthesia claim used the QZ modifier. Yet despite the fact that all 9,071 anesthesia claims used only the modifier, physician anesthesiologists were affiliated with 47.5% of these hospitals.

anesthesiaexperts.com

QZ Modifier Found Not Representative of CRNA-Only Care - Anesthesia Experts

In stark contrast to a 2010 investigation suggesting that nurse anesthetists frequently provide care unsupervised by physician anesthesiologists, researchers at the University of Texas Medical Branch and the American Society of Anesthesiology’s (ASA) Department of Health Policy have found that...
anesthesiaexperts.com anesthesiaexperts.com
 
QZ billing for cases while actually supervising CRNAs is not fraudulent billing. CMS permits CRNAs to receive 100% of the allowed reimbursement regardless of whether an anesthesiologist is involved in the case. Insurance companies like CIGNA have decided to add some teeth to the QZ modifier and deduct 15% for cases billed that way. This means the group/hospital can bill Medical Direction (if they meet TEFRA) or continue billing QZ.

As has been pointed out, the billing codes like 'QZ' have nothing to do with legal liability. If you are involved with the case in any way then you are likely liable for the malpractice if any occurs. That's why most practices billing QZ still have an anesthesiologist's name on the chart.
 
Another thing to consider is that QZ is not even an option when the CRNAs are employed by the hospital.
 
abolt18 said:
False. As I stated above, my residency program bills everything QZ for every anesthetic involving a crna.
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Then I guess both the CRNAs and physicians are employed by the hospital. Because if the physicians are part of a private practice and the CRNAs are hospital employees, QZ is not an option.
 
rick roller pump said:
As Blade noted, the only reason to bill QZ would be if you were >4:1, or letting CRNAs basically do their own thing. I probably would not take a job like this but if I did I would need a huge salary. A co-resident of mine took a job at a system that I believe was set up like this and he was making serious money, like 800 I believe.
Click to expand...

You can make that doing MD only. I know of several groups where this is true.
 
potcake76 said:
How so?
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Private group of docs. Hospital employs CRNAs who cover OB epidurals solo. Doc is available and medico legally liable and available for consult problems. Bill QZ for their work. Docs get paid nothing for this subset of work/liability. Make it up on the subsidy.
 
If your name is on the chart you can and will be sued. (This includes a situation where you handed off a case to an MD colleague and something happens under their watch, expect to be named). Billing is another matter entirely. Remember, you can be sued even if you don’t submit a bill…
 
Dr. Rude said:
Private group of docs. Hospital employs CRNAs who cover OB epidurals solo. Doc is available and medico legally liable and available for consult problems. Bill QZ for their work. Docs get paid nothing for this subset of work/liability. Make it up on the subsidy.
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Fair enough. What I should have said is that the group would not be able to bill QZ. In the scenario you described, only the hospital would be able to bill QZ.
 
As someone who primarily does solo, how do the QY bill. Does supervising one CRNA bill less than 2 or 3; like at the end of the day if I'm down to one room and available for OB, is it better to relieve the CRNA if OB is safe enough?
For the QX, I'm assuming this is for states where independent practice isn't available, does this bill less?
 
Arch Guillotti said:
Reference?
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Don’t think you need a reference. Just the ability to bill for the crna.

To bill for anyone, MD or Crna - you need to credential them under your tax ID and contracts. Then bill.

Usually if crna is employed with hospital they are under hospital tax ID and hospital contract and hospital bills.

I’ve heard of places where there is a back door stipend. Hospital technically employs CRNAs-pays salaries/benefits. But allows MDs to list under their tax ID an and bill with their contracts.

If you have that set up, good for you! Maybe best stipend around.

Make sure they aren’t billing too though, if so, you may have to pay back some money!
 
abolt18 said:
My hospital I trained at did this for all the crnas. QZ across the board. Medical bylaws required medical direction, but I think it's a convenience factor when it comes to less boxes to check.
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So they violate their own medical staff bylaws with every case?
 
jwk said:
So they violate their own medical staff bylaws with every case?
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I don't know exactly what the bylaws stated. I know they required physician involvement, but I don't know if it specifically stated medical direction or supervision...
 
abolt18 said:
I don't know exactly what the bylaws stated. I know they required physician involvement, but I don't know if it specifically stated medical direction or supervision...
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And that's key. Medical staff bylaws can always be more restrictive than state and federal law, and that includes "opt-out" states. They can't be more permissive.
 
Question:

Can you explain what ‘delegation’ by anesthesiologists mean?

In Texas.

Please explain to me as if I’m 5 years old.

It’s not a routinely used term like direction or supervision in anesthesia.

One of the practices I work for insists on crna independence yet MD (anesthesiologist; non- anesthesia physicians have refused to delegate the CRNA at this facility) is the ‘delegating physician’.

The anesthesiologist name (not the signature) must be on the consent.

This scenario is especially concerning on call when the anesthesiologist is doing a case and also supposedly ‘delegating’ to OB CRNA.

Is this kosher?
 
In business the saying is ‘you can delegate authority but not responsibility’. If that’s the case here it doesn’t sound like a favorable setting to practice in.
 
Thank you.

When I bring this up, the leadership changes the answer to ‘well it’s qz modified billing’ ie crna at a seperate facility working independently while the ‘delegating physician’ is either at home or at a different facility.

The issue here is not really about billing is it?

The issue here is about consent and ability to proceed in the first case because the anesthesiologist is not ‘immediately available’.

Someone also mentioned above the importance of facility bylaws.

My second question is what takes priority? State occupational code or specific facility bylaws?
I find the state occupational code more open and general - but the facility bylaws are more restrictive.
 
Delegation hasn’t been a word traditionally used in the doctor and nurse relationship. The wording has been used by the Texas nursing board.
“ Delegation--means that a registered nurse authorizes an unlicensed person to perform tasks of nursing care in selected situations and indicates that authorization in writing. The delegation process includes nursing assessment of a client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, ensuring supervision of the unlicensed persons and re-evaluating the task at regular intervals. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.”
 
“What is the meaning of delegation in nursing?


Delegation generally involves assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. The registered nurse cannot delegate responsibilities related to making nursing judgments.”
 
The above quote is from the ANA’s principles for delegation.

Sounds like Texas is utilizing some traditionally nursing lingo for the doctor and crna relationships.

“While retaining responsibility for the outcome….”

Delegation = “being held responsible.”
 
Last edited:
neutro said:
Question:

Can you explain what ‘delegation’ by anesthesiologists mean?

In Texas.

Please explain to me as if I’m 5 years old.

It’s not a routinely used term like direction or supervision in anesthesia.

One of the practices I work for insists on crna independence yet MD (anesthesiologist; non- anesthesia physicians have refused to delegate the CRNA at this facility) is the ‘delegating physician’.

The anesthesiologist name (not the signature) must be on the consent.

This scenario is especially concerning on call when the anesthesiologist is doing a case and also supposedly ‘delegating’ to OB CRNA.

Is this kosher?
Click to expand...
No it’s not kosher. You can’t delegate while soloing. Google toussaint anesthesiologist- this is one of the many things he got in trouble for. My friend worked for him for awhile and eventually she was asked to put her name on charts while she was home sleeping post call or over the weekend where she wasn’t in the hospital. She refused and quit.

I know this situation so won’t share specifics… will leave it to the OP… but someone from your corporate overlords or hospital admin has to explain to the crnas that Texas is not an independent practice state…. It’s state law and above the authority of the Aana etc.

Delegation implies accountability and responsibility for the outcome.
I think it’s illegal and fraudulent but a lawyer would be able to tell you for sure.

It’s not going to be a problem… until it’s a problem…. And corp overlords and hospital admin dump the problem n the anesthesiologist lap.

In case a jury finds you guilty of gross negligence (like patient abandonment ) your malpractice insurer will not pay…. That means you are financially on the hook for a potential multi- million dollar lawsuit… and likely personal bankruptcy.

Malpractice attorneys will have a field day with this… very good for them
 
neutro said:
Question:

Can you explain what ‘delegation’ by anesthesiologists mean?

In Texas.

Please explain to me as if I’m 5 years old.

It’s not a routinely used term like direction or supervision in anesthesia.

One of the practices I work for insists on crna independence yet MD (anesthesiologist; non- anesthesia physicians have refused to delegate the CRNA at this facility) is the ‘delegating physician’.

The anesthesiologist name (not the signature) must be on the consent.

This scenario is especially concerning on call when the anesthesiologist is doing a case and also supposedly ‘delegating’ to OB CRNA.

Is this kosher?
Click to expand...
Delegation by an anesthesiologist as described by a hospital is not a defined term.

That being said - CAAs function in Texas under delegatory authority granted by the Texas Medical Board, and such practice is regulated by the Board. This is NOT the same as what you're concerned about with CRNAs. QZ billing implies no medical direction. Any attempt by the hospital to call this "delegation" is absurd, and it is certainly not defined in CMS regulations, where you will only find medical direction or supervision. CAAs practice under delegatory authority AND are medically directed per CMS regulations (TEFRA, etc.)

CAAs have sought licensure in Texas the last several sessions, but of course the CRNAs mount their usual full anti-competitive assault as soon as the legislation is filed. Gotta wonder what they're so afraid of.
 
RedandBlack7 said:
Would anyone here ever tolerate a QZ supervision set-up, especially at a busy high acuity practice?
Click to expand...
people will do it for a price. Typical 1.5 - 2x typical hourly anesthesia rates….and I guess just count on a lawsuit every few years.
 
The qz billing isn’t necessarily the issue - until recently if you owned the crnas billing qz or med supervision paid the same. Billing and liability are two different things
The supervision ratio is the issue…. Supervising so many rooms (>4) that you could never adequately know what’s going on in a room or in a malignant crna environment where they marginalize the dr and don’t call them for anything - that’s the real issue.
It’s called care team for a reason… you’re supposed to be a team - and that requires an good crna relationship and 4 to 1 or less ratios.
 
dannyboy1 said:
If your name is on the chart you can and will be sued. (This includes a situation where you handed off a case to an MD colleague and something happens under their watch, expect to be named). Billing is another matter entirely. Remember, you can be sued even if you don’t submit a bill…
Click to expand...

That’s why I always submit a bill.
If I am liable, need to be paid.

[emoji1787]
 
In general our profession does a terrible job (on the rare times they even make an attempt) of teaching residents ANYTHING about billing. Then we go out into the world not understanding how/what to do in order to get paid.

Are there any good resources, courses etc for teaching anesthesiologists the ins and outs of billing?
 
There are a lot of practices, particularly in rural environments, where there are a couple of anesthesiologists and a ton of CRNAs. Are these docs taking the liability for every CRNA? For example, I interviewed for a job where there were 14 ORs, including cardiac cases, and 2 physicians daily. I didn’t take the job (or really even consider it), so I’m a bit light on the details. I was told the docs helped get the hearts launched and were available to assist with other cases. Would these two docs be on the hook for the liability for every OR? I hate the idea of this, but patients in rural areas also need care, so I’m conflicted. This was in Kentucky.
 
Pharmado said:
There are a lot of practices, particularly in rural environments, where there are a couple of anesthesiologists and a ton of CRNAs. Are these docs taking the liability for every CRNA? For example, I interviewed for a job where there were 14 ORs, including cardiac cases, and 2 physicians daily. I didn’t take the job (or really even consider it), so I’m a bit light on the details. I was told the docs helped get the hearts launched and were available to assist with other cases. Would these two docs be on the hook for the liability for every OR? I hate the idea of this, but patients in rural areas also need care, so I’m conflicted. This was in Kentucky.
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Yes.
Because anesthesiology is a discipline of medicine, not nursing - so medical staff bylaws apply which means that all patients must have a physician, not a nurse be ultimately responsible for care.
That can mean different things at different places.
If it’s a crna only practice, the physician - most commonly the surgeon is responsible.
 
This is horrible for care. If physicians have to choose between accepting liability for circumstances they can’t control or leaving patients in the hands of less qualified providers, patients are the ones who lose.
 
Pharmado said:
There are a lot of practices, particularly in rural environments, where there are a couple of anesthesiologists and a ton of CRNAs. Are these docs taking the liability for every CRNA? For example, I interviewed for a job where there were 14 ORs, including cardiac cases, and 2 physicians daily. I didn’t take the job (or really even consider it), so I’m a bit light on the details. I was told the docs helped get the hearts launched and were available to assist with other cases. Would these two docs be on the hook for the liability for every OR? I hate the idea of this, but patients in rural areas also need care, so I’m conflicted. This was in Kentucky.
Click to expand...
Yes. Just interview with job in Missouri. Manage 3-6 rooms only go in room for concerning inductions. Hearts, peds, otherwise stick around pre-op
 
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