Certified Registered Nurse Anesthetist (CRNA) Practice and Chronic Pain Management

Section 1861 of the Social Security Act defines services of a Certified Registered Nurse Anesthetist (CRNA) to mean anesthesia services and related care furnished by a certified registered nurse anesthetist, which the nurse anesthetist is legally authorized to perform as such by the State in which the services are furnished. This legislative statute forms the basis for the coverage of CRNA services by the Medicare program. Services meeting this definition are billable to Medicare when all medical necessity criteria have been met.

Anesthesia Services

The definition of anesthesia services is based on American Society of Anesthesiologists most recent set of practice guidelines (Anesthesiology 2002; 96:1004-17). Anesthesia services are divided into 2 categories; anesthesia and analgesia.

Category 1: Anesthesia, specifically including
General anesthesia
Regional anesthesia
Monitored anesthesia care (MAC), including deep sedation
Category 2: Sedation/analgesia, specifically including
Topical or local anesthesia
Minimal sedation
Moderate sedation/analgesia ("Conscious Sedation")

Related Care

CMS Internet Only Manual (IOM) 100-04 - Medicare Claims Processing Manual, Chapter 12, Section 140.4.3 - Payment for Medical or Surgical Services Furnished by CRNAs lists additional services that a CRNA may bill for when they are related to anesthesia care provided. "Related to" is defined as occurring before, during or immediately after the administration of anesthesia. These services may include: insertion of central venous pressure lines, pain management, emergency intubation, and the pre-anesthetic examination and evaluation of a patient who does not undergo surgery.

Chronic Pain Management

Chronic pain is the common symptomatic manifestation of a wide range of underlying medical conditions. Treatment of the chronic pain disorder begins with a detailed medical assessment aimed at developing a diagnosis or diagnostic evaluation plan, which will then lead to an appropriate and comprehensive therapeutic plan. The assessment skills required for the evaluation of the chronic pain state and the development of the consequent plan of care not part of the CRNA training curricula. If the CRNA is an Advanced Registered Nurse Practitioner (ARNP) or Clinical Nurse Specialist (CNS), or working incident to a physician or Non-Physician Practioner (NPP), epidural injections may be reimbursed incident to the physician's or NPP's (NP, CNS, and PA) management of a patient with chronic pain when such services are medically reasonable and necessary.

Billing the Appropriate Contractor

The CMS Internet-Only Manual (IOM) 100-04 - Claims Processing Manual, Chapter 4, Sections 250.3.3.1 and 250.3.3.2 include information regarding billing for CRNA anesthesia services. The HCPCS code range in this section contains the anesthesia HCPCS codes that CRNAs may bill. This regulation does not include a HCPCS code range for the additional services that a CRNA may bill for as defined by CMS Internet Only Manual (IOM) Publication 100-04 - Medicare Claims Processing Manual, Chapter 12, Section 140.4.3. Critical Access Hospitals (CAH) should use the guidelines listed below to determine the appropriate form to use when billing for CRNA services.

If a CAH who meets the criteria for a pass-through exemption, is interested in selecting the Method II option, it can choose this option for all outpatient professionals except the Certified Registered Nurse Anesthetist (CRNA) and still retain the approved CRNA exemption for both inpatient and outpatient professional services of CRNAs. With an approved exemption, the CAH can choose to give up its exemption for both inpatient and outpatient professional services of CRNAs in order to include its CRNA outpatient professional services along with those of all other professional services under the Method II option. By choosing to include the CRNAs under Method II for outpatient services, the CAH loses its CRNA pass-through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case, the CAH would have to bill the Part B carrier for the CRNA inpatient professional services.

All payments for CRNA services are subject to cost settlement. If a CAH that meets the criteria for a pass-through exemption is not interested in selecting the Method II option, the CAH can still receive the CRNA pass-through under the standard option (Method I).

Method I

Billing requirements:

  • Method I without a pass through exemption: bill professional services using CMS-1500 and technical services using CMS-1450
  • Method I CMS with a pass thru - CMS-1450
  • Type of Bill (TOB) = 85X and 11X.
  • Revenue code 037X for CRNA technical services.
  • Revenue code 0964 for professional services.

Method II - Receiving the CRNA Pass-Through

Billing requirements:

  • CMS-1450
  • TOB = 85X.
  • Revenue code 037X for CRNA technical services.
  • Revenue code 0964 for CRNA professional services.

Method II - Gave Up CRNA Pass-Through Exemption (or Never Had Exemption)

Billing requirements:

  • CMS-1450
  • TOB = 85X.
  • Revenue code 037X for CRNA technical services.
  • Revenue code 0964 for CRNA professional services.

Page Last Updated: Tuesday, 20-Sep-2011 11:43:01 CDT