CMS Pub. 100-04, ch. 4, § 250.3.3.1

Rural hospitals and Critical Access Hospitals (CAHs) or hospitals/CAHs reclassified to a

rural area can qualify for reasonable cost reimbursement of anesthesia services

performed in the hospital or CAH by a qualified non-physician anesthetist if they meet

certain criteria and obtain approval for the CRNA/AA cost reimbursement. Non-physician anesthetists are defined as certified registered nurse anesthetists (CRNAs)

and anesthesiologist assistants (AA).

CAHs are eligible to receive CRNA pass-through payments (“pass-through

exemption”) for both inpatient and outpatient services if they meet criteria discussed at

42 CFR § 412.113(c) of the regulations. CRNA pass-through payments and the

Method II election for outpatient CAH services are applied as described below. Note

that for CAHs that have a CRNA pass-through exemption, all CRNA services

provided to CAH swing-bed patients must be included on the CAH swing-bed bill.

(See MCPM, Ch. 3, 60 and 100.2 for more information)

If a CAH meets the criteria for a pass-through exemption and is interested in selecting

Method II for its physicians and/or other practitioners, it can choose Method II for all

outpatient professionals except the CRNAs and still retain the approved CRNA pass-through exemption for both inpatient and outpatient CRNA professional services.

The hospital may elect the CRNA exemption under 42 CFR 412.113.

Facilities pursuing CRNA cost reimbursement for anesthesia services must

submit copies of the following information with your request to their Medicare

Administrative Contactor (MAC):

• Written, signed, and dated agreements with the CRNA/AAs under contract or

employment for services to be rendered during the calendar year. Hospitals

or CAH may employ or contract with more than one anesthetist, however,

the total number of hours of service furnished by the anesthetists may not

exceed 2,080 hours per year.

• Current CRNA/AA license.

• Surgical procedure logs (inpatient and outpatient) for the facility’ s entire

patient population demonstrating the number of surgical hours and number of

surgeries requiring anesthesia services (include name of CRNA/AA and

surgical hours utilized for each procedure) for the period January 1 –

September 30 each calendar year. Annualized surgical procedures for this

period should not exceed 800 surgeries.

• Written, signed, and dated attestation agreements stating that the CRNA/AA

has not and will not be billed on a reasonable charge basis for his or her

patient care to Medicare beneficiaries in that hospital or CAH for the

calendar year.

• Documentation that the hospital or CAH is located in a rural area as

defined for prospective payment system purposes or has been reclassified

as rural under 42 CFR 412.103.

Note: CRNA services where the provider has elected the cost reimbursement

pass-through exception do not require that the CRNA perform a formal

reassignment of benefits with an 855I or the 855A.

Alternatively, a CAH, with an approved pass-through exemption, can choose to give

up its pass-through exemption for both inpatient and outpatient CRNA professional

services in order to include its CRNA outpatient professional services under Method

II. By choosing to include the CRNA 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 A/B MAC (B) for the CRNA inpatient professional services. All A/B MAC

(A) payments for CRNA services are subject to cost settlement.

Provider Billing Requirements for CRNA Pass-Through

TOBs = 11X and 18X

Revenue Code 037X for

CRNA technical services

Revenue Code 0964 for

Professional services

Reimbursement

Revenue Code 37X, CRNA technical service = Cost Reimbursement (101

percent of reasonable cost)

Revenue Code 0964, CRNA professional service = Cost Reimbursement (100

percent of reasonable cost) for both inpatient (including swing-bed) and

outpatient

Deductible and coinsurance apply.

Provider Billing Requirements for CRNA Pass-Through

TOB = 85X

Revenue Code 037X for

CRNA technical services

Revenue Code 0964 for

Professional services

Anesthesia HCPCS codes and for any HCPCS codes for services the CRNA is

legally authorized to perform in the state in which the services are furnished.

The appropriate HCPCS should be included when required for the applicable

TOB and or revenue code.

Reimbursement

Revenue Code 37X, CRNA technical service = Cost Reimbursement (101

percent of reasonable cost)

Revenue Code 0964, CRNA professional service = Cost Reimbursement (100

percent of reasonable cost) for both inpatient (including swing-bed) and

outpatient

Deductible and coinsurance apply.

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to

receive CRNA pass- through payments for services that the CRNA is legally authorized

to perform in the state in which the services are furnished.

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