-QZ

Modifier -QZ: CRNA Without Medical Direction

Short Definition

The CRNA personally performed and fully managed the entire anesthesia service without medical direction or supervision by a physician.

Long Definition

Modifier -QZ is a HCPCS Level II anesthesia payment modifier reported exclusively by a CRNA (Certified Registered Nurse Anesthetist) to indicate they provided the entire anesthesia service independently, without medical direction or supervision by a physician. No anesthesiologist or other physician was involved in directing, overseeing, or co-managing the anesthesia care.

Modifier -QZ is the CRNA equivalent of modifier -AA — just as -AA signals a physician anesthesiologist personally performed the full case, -QZ signals the CRNA performed the full case independently. Reimbursement is at the full applicable CRNA fee schedule rate (100%), with no payment split required since no physician directed the case.

-QZ is particularly relevant in states where the governor has opted out of the Medicare physician supervision requirement for CRNAs, as well as in facilities and practice settings where CRNAs practice independently under state law and facility credentialing.

Who Reports Modifier QZ

• CRNA only.
• Anesthesiologist assistants (AAs) do not use -QZ — AAs always practice under physician direction and report -QX.
• Physician anesthesiologists do not use -QZ.
• -QZ is CRNA-specific and is not interchangeable with any other modifier.

When to Use

• The CRNA performed the entire anesthesia service from pre-anesthesia evaluation through post-anesthesia care.
• No physician was medically directing or supervising the CRNA’s work.
• The CRNA is practicing independently under applicable state law and facility credentialing.
• The facility/state allows independent CRNA practice (Medicare opt-out states or state scope-of-practice laws).

When NOT to Use

• When the CRNA is working under the medical direction of a physician anesthesiologist — use -QX instead.
• When the CRNA is working under medical supervision (physician is present but not meeting medical direction standards) — payer policy varies; many require -QX with -AD on the physician’s side in supervision scenarios.
• When an anesthesiologist personally performed the case — use -AA instead.
• Never report -QZ on the same claim line as -AA, -QK, -QX, -QY, or -AD — these are mutually exclusive.

Reimbursement

• CRNA bills -QZ: 100% of the applicable CRNA anesthesia fee schedule allowable.
• No paired billing is required — no physician is involved, so there is no payment split.
• Calculated as: (Base Units + Time Units + Modifying Units) × CRNA Conversion Factor = Allowable.

Medicare Supervision Opt-Out Note

• Under CMS Medicare rules, CRNAs are normally required to be under physician supervision unless the state governor has submitted a letter to CMS opting out of the supervision requirement.
• In opt-out states, CRNAs may practice fully independently for Medicare patients without physician involvement.
• In non-opt-out states, independent CRNA billing with QZ for Medicare patients may require specific documentation confirming compliance with applicable supervision rules or a qualifying exception.
• Always verify the opt-out status of your state and facility policy when billing QZ for Medicare.

Teaching CRNA Scenario

• When a CRNA (not under physician direction) is overseeing two concurrent student nurse anesthetist cases, the CRNA reports both cases with modifier -QZ per CMS guidance.

Anesthesia Payment Modifier Family — Quick Reference

Modifier	Reported By	Scenario	Rate
-AA	Anesthesiologist	Personally performed, full case	100%
-QK	Anesthesiologist	Medically directing 2-4 concurrent cases	50%
-QY	Anesthesiologist	Medically directing 1 CRNA	50%
-AD	Anesthesiologist	Supervising 5+ concurrent cases	Limited base units only
-QX	CRNA / AA	Medically directed by a physician	50%
-QZ	CRNA	Without medical direction by a physician	100% CRNA rate

Quick Example

• A CRNA in an independent practice state performs the full anesthesia service for a knee arthroscopy (01382).
• No anesthesiologist is present or involved.
• CRNA bills: 01382-QZ under their own NPI.
• Reimbursement: full CRNA anesthesia allowable for that CPT code.
• Documentation: complete anesthesia record reflecting CRNA-only care.

Related Modifiers

• -AA
• -QK
• -QX
• -QY
• -AD