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-QY

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⚕️ Modifier QY - Anesthesiologist Directing One Certified Registered Nurse Anesthetist

Quick Reference

Descriptor: Anesthesiologist directing one certified registered nurse anesthetist 1
Global Period: Follows the primary anesthesia procedure code 2
Provider Type: Anesthesiologist (MD/DO) directing a CRNA 3
Reimbursement: Medicare pays 50% of the allowed anesthesia amount to the anesthesiologist 4
NCCI Status: Subject to medical direction rules (Tefra regulations) 5
Approach: Appended to Anesthesia CPT® codes (00100-01999)

📋 Code Description & Clinical Context

Modifier -QY is a HCPCS Level II modifier used to identify when an anesthesiologist is medically directing one certified registered nurse anesthetist (CRNA) during a surgical procedure 1. This modifier is part of the “-AA, -QK, -QY, -QX, -QZ” series used to define the relationship between anesthesia providers and determine reimbursement splits under Medicare and many commercial plans 3.

Key Usage Indications:

  • An anesthesiologist is medically directing a single CRNA
  • The anesthesiologist performs specific medical direction tasks (pre-op exam, prescription, participation in critical portions, monitoring, post-op care)
  • The CRNA performs the hands-on administration of anesthesia
  • Documentation supports the medical direction relationship per Tefra regulations

Medical Direction Requirements

To bill -QY, the anesthesiologist must meet the “medical direction” criteria: performing pre-anesthetic examination, prescribing the anesthesia plan, personally participating in critical portions, ensuring qualified individuals perform other tasks, monitoring anesthesia administration, and providing indicated post-anesthesia care 6.

🌲 Code Hierarchy / Context

HCPCS Level II Modifiers
└─ Anesthesia Modifiers
   ├─ -AA Anesthesia services performed personally by anesthesiologist
   ├─ -QK Medical direction of two, three, or four CRNAs
   ├─ -QY Anesthesiologist directing one certified registered nurse anesthetist ← THIS CODE
   ├─ -QX CRNA service with medical direction by a physician
   └─ -QZ CRNA service without medical direction by a physician

Parent Category: Anesthesia Modifiers 7
Related Modifiers: AA, QK, QX, QZ, AD (Supervision >4 cases)
Primary Code Dependency: Must be appended to a valid Anesthesia CPT® code (e.g., 00100, 00300)

💰 Reimbursement & Valuation

ComponentRateNotes
Base Rate100%Based on the allowed amount for the Anesthesia CPT® code 4
Anesthesiologist Share50%Standard reimbursement rate for medical direction of one CRNA 4
CRNA Share50%CRNA bills separately with modifier QX for the remaining 50% 4
Final QY Rate50%Of the total allowed anesthesia fee schedule amount 4
Global PeriodSame as PrimaryAnesthesia services are paid per unit/time; no global period in surgical sense 2

Assistant Surgeon Payable: N/A (Anesthesia Direction)

  • Medicare Status Indicator: Depends on primary anesthesia code coverage 7
  • If medical direction requirements are not met, reimbursement may be denied or reduced
  • Commercial payers may vary (some follow Medicare 50/50 split, others have contracted rates)

Medicare Payment Estimate: Varies by anesthesia base units + time units × Conversion Factor × 50% 4

🚫 Includes / Excludes & NCCI Guidance

✅ Includes

  • Medical direction of a single CRNA by an anesthesiologist
  • Pre-operative anesthesia evaluation by the anesthesiologist
  • Participation in critical portions of the anesthesia plan
  • Post-operative anesthesia care by the anesthesiologist
  • Monitoring of the CRNA’s administration

❌ Excludes / Bundled Per NCCI

  • Personal performance of anesthesia (use AA if anesthesiologist does it all) 3
  • Medical direction of 2-4 CRNAs (use -QK) 3
  • Medical supervision of >4 concurrent procedures (use AD) 3
  • CRNA services without medical direction (CRNA uses -QZ) 3
  • Services not meeting Tefra medical direction criteria (may be denied) 6

Tefra Regulations Critical Note

Modifier -QY is governed by federal regulations (Tefra). If the anesthesiologist is concurrently directing more than one CRNA, QY is incorrect; QK must be used. If the anesthesiologist fails to meet the 7 steps of medical direction, payment may be denied 6.

🏥 MS-DRG Assignment (Inpatient Facility)

Modifier QY does not directly impact MS-DRG assignment, as DRGs are based on the primary surgical procedure and diagnoses. It affects physician reimbursement under Medicare Part B.

ScenarioImpactDescription
Anesthesia medically directedPayment SplitAnesthesiologist paid 50%, CRNA paid 50% 4
Anesthesia personally performedFull PaymentAnesthesiologist bills AA for 100% 4
Inpatient StatusPart B BillingAnesthesia services billed on CMS-1500/837P 8

Note

Facility reimbursement (Part A) is not affected by modifier QY; this modifier is for professional fee billing only 8.

🏷️ Common ICD-10-CM Diagnosis Codes

Modifier -QY does not change diagnosis coding requirements. Diagnosis codes must support the medical necessity of the primary surgical procedure and anesthesia.

Primary Diagnosis Options (Dependent on Procedure)

ICD-10-CM CodeDescriptionHCC Status*
K80.20Calculus of gallbladder without cholecystitis❌ Not HCC
M17.11Unilateral primary osteoarthritis, right knee❌ Not HCC
C67.9Malignant neoplasm of bladder✅ HCC (Cancer)
Z40.01Encounter for prophylactic surgery for malignant neoplasm✅ HCC (History of Cancer)
I10Essential (primary) hypertension✅ HCC (Cardiovascular)

* HCC Status: Hierarchical Condition Category mapping for Medicare Advantage risk adjustment. Diagnosis codes determine HCC status, not the modifier. Modifier QY has no impact on risk adjustment scores 910.

Supporting/Comorbid Codes (Document When Applicable)

  • N18.30 Chronic kidney disease, stage 3 unspecified (HCC applicable)
  • E11.9 Type 2 diabetes mellitus without complications (HCC applicable)
  • J44.9 Chronic obstructive pulmonary disease, unspecified (HCC applicable)

✏️ Modifiers Guidance

ModifierUse Case for QYPayable?
-AAAnesthesia performed personally by anesthesiologist❌ Do not use with QY
-QKMedical direction of 2-4 CRNAs❌ Do not use with QY
-QXCRNA service with medical direction✅ Used by CRNA when anesthesiologist bills QY
-QZCRNA service without medical direction❌ Mutually exclusive with QY relationship
-ADMedical supervision >4 procedures❌ Do not use with QY
-47Anesthesia by Surgeon❌ Mutually exclusive
-23Unusual Anesthesia✅ Can be used with QY if unusual circumstances exist

Modifier QY vs QK

Do not use modifier -QY if the anesthesiologist is directing more than one CRNA concurrently. Use -QK for 2-4 CRNAs. Using QY for multiple CRNAs may trigger audit or recoupment 3.

📝 Coding Examples

✅ Example 1: Anesthesiologist Directing One CRNA

Scenario: Patient undergoes knee arthroscopy. Anesthesiologist medically directs one CRNA. Anesthesiologist performs pre-op exam, participates in induction, monitors, and provides post-op care.
Report:

  • Anesthesiologist: 00402--QY
  • CRNA: 00402--QX
  • Diagnosis: M17.11
    Rationale: One CRNA directed; correct modifier split used 11.

❌ Example 2: Anesthesiologist Directing Two CRNAs

Scenario: Anesthesiologist directs two CRNAs in two different ORs simultaneously. Bills -QY.
Report: 00402--QY
Rationale: Incorrect. When directing 2-4 CRNAs, modifier -QK must be used. -QY is for one CRNA only 3.

⚠️ Example 3: Personal Performance

Scenario: Anesthesiologist performs all anesthesia services personally without CRNA. Bills -QY.
Report: 00402--QY
Rationale: Incorrect. If personally performed, modifier AA should be used for 100% reimbursement 3.

✅ Example 4: Unusual Anesthesia with Direction

Scenario: Patient has severe cardiac disease requiring unusual anesthesia techniques. Anesthesiologist directs one CRNA.
Report:

  • Anesthesiologist: 00402-QY-23
  • CRNA: 00402-QX-23
  • Diagnosis: I10, M17.11
    Rationale: Modifier 23 indicates unusual anesthesia; QY indicates direction relationship 11.

🔍 Documentation Essentials for Support

To support modifier QY and mitigate audit risk, anesthesia documentation should include:

  1. Medical Direction Tasks: Document the 7 steps of medical direction (pre-op, plan, critical portions, etc.) 6.
  2. Concurrency: Clearly state how many CRNAs are being directed concurrently (must be one for QY).
  3. Presence: Anesthesiologist must be physically present during critical portions.
  4. Availability: Anesthesiologist must be immediately available for emergencies.
  5. Signatures: Both anesthesiologist and CRNA must sign the anesthesia record.
  6. Time: Document start and stop times for anesthesia care.

Medical Record Language

Ensure the anesthesia record states: “Anesthesiologist medically directed one CRNA. Pre-operative evaluation performed. Participated in induction and emergence. Monitored throughout procedure.”

⚠️ Common Pitfalls & Audit Risks

PitfallConsequencePrevention
Using QY for >1 CRNAClaim denial or recoupmentUse QK for 2-4 CRNAs 3
Failing to meet Tefra criteriaPayment denialEnsure all 7 medical direction steps are documented 6
Using QY for personal performanceUnderpaymentUse AA if anesthesiologist performs all services 3
Missing CRNA modifier QXClaim mismatchCRNA should bill QX when anesthesiologist bills QY 11
Inadequate time documentationPayment reductionDocument exact anesthesia time units 11

🔗 Related Codes & Crosswalks

Code TypeCodeRelationship to QY
HCPCS ModifierAAAnesthesia services performed personally by anesthesiologist
HCPCS ModifierQKMedical direction of two, three, or four CRNAs
HCPCS ModifierQXCRNA service with medical direction by a physician
HCPCS ModifierQZCRNA service without medical direction by a physician
HCPCS ModifierADMedical supervision by a physician; more than four concurrent anesthesia procedures
CPT®00100-01999Anesthesia Procedure Codes
CMS FormCMS-1500Professional claim form where QY is reported

1 CMS HCPCS Level II Modifier Definitions
2 CMS Global Surgery Factsheet
3 Medicare Claims Processing Manual Ch. 12
4 CMS Medicare Physician Fee Schedule 2024
5 CMS NCCI Policy Manual 2024
6 CMS Tefra Regulations Guidance
7 NIH VSAC HCPCS Hierarchy
8 Medicare Claims Processing Manual Ch. 1
9 CMS-HCC Model V28 Documentation
10 Find-A-Code HCC Mapping Tool
11 AAPC Coding Modifier Guidelines
12 ASA Guidelines for Medical Direction

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