CRNA Identity Threats

Urgent Priority Initiative: Updates Needed for CRNA Modifier Codes

By Jean Covillo, DNAP, MA, APRN, CRNA

The ASA’s rationale for a dominant position in the market depends on their ability to provide evidence of improved outcomes relative to CRNAs.  “This is not too difficult if the evidence collected contains ambiguously generated  data  from two separate and distinct provider categories.” Jean Covillo, DNAP, MA, CRNA

CRNA Professional Identity is threatened  through efforts by the American Society of Anesthesiologists (ASA) to create an “alternative” reality where Anesthesia Assistants (Assistants) are proffered as the substitute equivalent to the CRNA. Examples of this include changes in the name from Anesthesia Assistants to Certified Anesthetists, …sound confusing?  How about the ASA legislative efforts aimed at placing restrictions on the use of the term “anesthesiologist” or “anesthesiology” in the CRNA professional title?  These efforts ignore the basic fact that the term “anesthesiology” refers to the study of anesthesia which, last I checked, was not exclusive to the practice of medicine.  Regardless, the ASA believes the term to be proprietary.  But, probably the most worrisome effort staged so far, that is capable of altering perception, relates to the intermixing within the Medicare modifier code, QX.  QX is the code used to identify the anesthesia provider when  services are administered under medical direction.  This code informs Medicare that services were performed by a “qualified” non-physician provider, ie,  a CRNA or an Assistant.  But since both individuals share the same code-it isn’t possible to discern which provider type was involved in the service.   I think the ASA prefers this ambiguity.  You might be asking yourself, “Why is this happening?” and “What is the big deal?”

Why is this happening?

The ASA depends heavily on arguments of “increased safety” when making the case for the increased labor costs associated with services provided under the medical direction and supervision anesthesia delivery models.  The ASA’s rationale for a dominant position in the market depends on their ability to provide evidence of improved outcomes relative to CRNAs.  The easiest way to obtain “evidence” of improved outcomes relative to CRNAs is to intermix the data reported by CRNAs and Assistants without any distinction given to the provider “type.” Current medical direction modifier codes are shared between the CRNAs and Assistants. Both providers are required to identify themselves with the same modifier code when working as a member of the anesthesia care team (ACT).

Modifier Codes:  Currently Anesthesiologists have 5 codes that specifically address who they are and what type of delivery model is being used while CRNAs have only 1 that is specific to their identity.  The physician modifiers are as follows: 1) AA-Anesthesiologist alone, 2) QY -Anesthesiologists medically directing 1 “qualified” provider which includes both CRNAs and Anesthesia Assistants, 3) QK -Anesthesiologists medically directing 2-4 “qualified” anesthesia providers, 4) AD- Anesthesiologist supervising more than 4 concurrent procedures, and 5) GC-Anesthesiologist  medically directing a physician anesthesiologist in training.  CRNAs have only one modifier code that is specific to the CRNA provider; QZ, which is used by CRNAs when providing services independently without the medical direction of an anesthesiologist. CRNAs and Anesthesia Assistants both use the modifier QX when providing services under the medical direction of an Anesthesiologist.  CRNAs also use the QX modifier when working under the medical supervision delivery model. When anesthesiologists provide medical direction, there is no distinction made on the claim form  as to which “qualified” anesthesia provider (Assistant or CRNA) actually performed the service.  Although both CRNAs and Assistants are “qualified” to provide services alongside an anesthesiologist, the similarities end there.

CRNAS are Independent Providers

CRNAs undergo extensive training and education. Most have received Master’s degrees and current CRNA educational programs now require Doctoral degrees. CRNAs are licensed to independently provide all types of anesthesia services without any oversight or interference by an anesthesiologist.  CRNAs are recognized and reimbursed for independent practice by Medicare in all states at exactly the same rates as their physician counterparts.  So of course, CRNAs are “qualified” to provide services with an anesthesiologist under the medical direction model just as they are “qualified” to administer anesthesia services without any anesthesiologist at all.  Conversely, the Anesthesia Assistant is exactly what the name describes, an assistant whose services are ancillary to the physician anesthesiologist.  Assistants are not trained to work independently, cannot bill for services without an anesthesiologist, and are not legally authorized to provide services without close supervision by an anesthesiologist.

CRNAs have a long history of safe anesthesia delivery with more than 10 well-documented peer-reviewed studies over the past twenty years which have found no difference in quality or safety when CRNAs work alone as compared to CRNAs who work alongside anesthesiologists.  Conversely, the safety record of an Assistant is directly related to the degree of supervision administered by an anesthesiologist.  Studies have shown failures in anesthesiologist supervision 37% of the time even when supervising two providers, let alone the 4 providers they are authorized to oversee at one time.  This means that more than a third of all patients receiving anesthetics by Assistants, are undergoing lapses in coverage due to unavailability of the anesthesiologist during critical times of the procedure, and standard of care is not being met.  Remember, the 37% failure rate exists when supervision ratios involve 1 physician to 2 Anesthesia Assistants.  Imagine what the failure rate would be when ratios involve 1 physician to 4 Assistants.

When two completely different provider categories are intermixed in a non-discriminative fashion, the performance data is shared and cannot be easily distinguished.  If these providers also shared equivalent qualifications, ie, educational certification, training, licensure, and authority to bill there would be no issue with this approach.   But considering CRNAs are qualified and licensed to work independently while Assistants require strict supervision by an anesthesiologist, it is clear these providers share very little in common—hence my issue.  As a CRNA, I am not OK with CRNA safety and performance measures hinging on the performance of ancillary services provided by an assistant especially when I have no control over whether these assistants received adequate physician supervision.

Proper Coding Improves Evidence in Reporting

Modifiers are created to separate provider “types” in order to identify the services and skills associated with each classification and to track performance measures by providers.  These measures address safety, cost-efficiency, and quality of services. By creating a modifier specific to CRNAs, the two provider categories can be separated and compared through various reporting mechanisms.  When issues arise, root cause analyses can be conducted with targeted solutions.  When Assistants are involved in “failed” medical direction, due to lapses in supervision, the result and consequence is much more than a “concurrency” issue- -it is illegal for Assistants to provide services independently and doing so results in substandard care, patient safety is threatened, and the facility risks losing its licensure and accreditation.  Conversely, when supervision criteria are not met when working with CRNAs and the medical direction model fails, the modifier can be changed to QZ without concomitant reductions in standard of care, and CMS will reimburse at 100% the payment.

As it stands, all documented reporting involving CRNAs and Assistants are being lumped together into the same bucket.  There is no means to differentiate practice performance and safety records between these two different provider categories and other regulatory differences cannot be easily discerned.  While the performance and safety records of Assistants are enhanced from the addition of CRNA data, the same cannot be said for the CRNAs, especially when more than a third of the procedures are likely to involve substandard care due to lapses in supervision when medically directing Assistants.  A lumped together bucket of data will include high performance scores and  excellent safety results from CRNAs and more than likely, “not” so excellent results from Assistants which taken together equals mediocrity.  This is the “alternate reality” that is being presented through hard-core evidence and reports.  For these reasons, CRNAs must be given a unique code that is distinctly specific to their profession when working in the ACT. This distinction will serve to insulate the CRNAs from liability relative to negative outcomes unrelated to their care.  Since different regulatory rules apply to the Assistants, the modifiers used to identify each provider must differentiate between them on the billing claim so that accurate reporting mechanisms can be in place.

What’s the Big Deal?

No two types of providers with different skill-sets, licensure, and regulatory requirements  should be lumped together as the same provider when practice performance measures may be used to affect payment and licensure.  How would a GYN surgeon feel if they were lumped together with family practice when looking at hysterectomy complications, or perhaps a better example might include data collected without differentiation between an orthopedic spine specialist mixed together with the neurosurgeons under the same surgeon code. Or how about having the anesthesiologists and CRNA share the same codes?   It is no mystery why CRNAs and Assistants are being lumped together with one modifier code. The data collected from both increases the overall performance of Assistants and lowers the overall performance of CRNAs .  When taken together-you see mediocrity associated with the “non-physician” provider moniker.   This provides indisputable evidence that these providers are—desperately in need of an anesthesiologist to ensure the safety of the patient.  This would be funny—if it wasn’t working.

The ASA’s rationale for a dominant position in the market depends on their ability to provide evidence of improved outcomes relative to CRNAs.  This is not too difficult if the evidence contains ambiguously collected performance data  obtained from two separate and distinct provider categories.  The ASA’s ongoing efforts to persuade the public and other regulatory authorities to view the qualifications of CRNAs and Assistants as the same, serves only one purpose.  That purpose is not to improve patient safety or cost-efficiencies. Instead, these efforts ensure a dominant position in the market through the use of manipulated data as evidence supportive of improved outcomes when physicians are involved in the delivery of care.

This deceptive practice has to stop.  CRNAs must take the necessary steps to ensure their practice is protected from identity theft.  The first step involves working with CMS to create a new and unique modifier specific to the CRNA when providing services under the medical direction delivery model.