Modifier QZ- CRNA Service Without Medical Direction

Identifies anesthesia services personally performed by a certified registered nurse anesthetist without medical direction by a physician.

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What Is Modifier QZ?

Modifier QZ is used to identify anesthesia services furnished by a Certified Registered Nurse Anesthetist (CRNA) without medical direction by a physician.

CMS lists QZ as one of the anesthesia payment modifiers available to CRNAs. It distinguishes independently furnished CRNA anesthesia services from services reported with Modifier QX, which identifies a CRNA service furnished with physician medical direction.

Modifier QZ describes the billing relationship for the anesthesia service. It does not eliminate other federal, state, facility, or scope-of-practice requirements that may apply to the CRNA.

When to Use Modifier QZ

CRNA Performs the Anesthesia Service: The anesthesia service is furnished by a qualified CRNA.

No Physician Medical Direction: The CRNA's service is not medically directed by a physician for Medicare anesthesia payment purposes.

Anesthesia Payment Modifier Is Required: QZ identifies the CRNA's payment status when reporting the applicable anesthesia service.

Applicable Requirements Are Met: The CRNA is legally authorized to perform the anesthesia service and satisfies applicable Medicare and state requirements. CMS notes that supervision requirements can vary based on the setting and whether a state has opted out of certain Medicare supervision requirements.

When NOT to Use Modifier QZ

CRNA Is Medically Directed: Modifier QX generally applies when the CRNA furnishes anesthesia under physician medical direction.

Anesthesiologist Personally Performs the Service: Modifier AA generally identifies anesthesia personally performed by an anesthesiologist.

Anesthesiologist Directs One CRNA: Modifier QY identifies the anesthesiologist's medical direction of one CRNA.

Service Does Not Meet CRNA Requirements: Do not report QZ when the individual furnishing the service does not meet applicable qualification, licensure, or billing requirements.

QZ Does Not Match the Actual Arrangement: The modifier should accurately represent whether physician medical direction occurred.

Billing Example

A CRNA personally provides anesthesia for a patient's surgical procedure without medical direction by a physician.

The CRNA reports the appropriate anesthesia code with Modifier QZ to identify the service as a CRNA anesthesia service without physician medical direction.

CMS currently lists QZ specifically for this billing circumstance.

Documentation Requirements

CRNA Participation: The anesthesia record should identify the CRNA who furnished the service.

Anesthesia Time: Document the actual anesthesia time according to Medicare requirements.

Anesthesia Record: Maintain a complete record describing the anesthesia care provided throughout the procedure.

Medical Direction Status: Documentation and billing information should accurately reflect that the service was not furnished under physician medical direction.

Medical Necessity: The medical record should support the anesthesia service and its relationship to the underlying procedure.

Applicable Requirements: Documentation should support compliance with applicable facility, state, and Medicare requirements.

Billing and Claim Considerations

Modifier QZ is an anesthesia payment modifier and should accurately represent how the anesthesia service was furnished.

CMS defines QZ as CRNA service without medical direction by a physician.

Medicare anesthesia payment is calculated using applicable base units, anesthesia time units, and the locality-specific anesthesia conversion factor. CMS confirms that the 2026 anesthesia base units remain unchanged from 2025.

Anesthesia time generally begins when the anesthesia professional starts preparing the patient for anesthesia in the operating room or equivalent area and ends when the patient may safely be placed under postoperative care.

Common Billing Mistakes

Using QZ for a Medically Directed CRNA: Modifier QX generally applies when physician medical direction is provided.

Confusing QZ With QY: QY represents an anesthesiologist's medical direction of one CRNA, while QZ represents a CRNA service without physician medical direction.

Assuming QZ Overrides Supervision Rules: QZ describes the medical-direction status for billing but does not override applicable federal, state, or facility requirements.

Incorrect Anesthesia Time: Inaccurate start or stop times can affect the calculation of anesthesia payment.

Missing Provider Documentation: The record should clearly identify the CRNA and support the anesthesia service performed.

Using the Wrong Payment Modifier: The modifier must correspond to the actual anesthesia arrangement for the case.

Common Denial Reasons

Incorrect Modifier: Claim information indicates physician medical direction even though QZ was reported.

Provider Qualification Issue: The billing provider does not satisfy applicable CRNA requirements.

Missing or Incorrect Anesthesia Time: Required time information is absent, inconsistent, or incorrectly reported.

Documentation Does Not Support Service: The anesthesia record does not adequately support the service billed.

Claim Information Conflict: Provider, procedure, or modifier information is inconsistent with the documented anesthesia arrangement.

Medical Necessity Not Supported: Documentation does not establish the medical necessity of the billed anesthesia service.

Modifier QZ vs. Modifier QX

Modifier QZ: CRNA anesthesia service without physician medical direction.

Modifier QX: CRNA anesthesia service with physician medical direction.

The primary difference is whether the CRNA's anesthesia service is furnished with or without physician medical direction. CMS continues to recognize both QX and QZ in its current CRNA billing guidance.

Frequently Asked Questions

Who reports Modifier QZ?
A CRNA uses QZ when reporting an anesthesia service furnished without medical direction by a physician, subject to applicable Medicare and state requirements.

Does Modifier QZ mean no physician can be involved in the patient's care?
No. QZ specifically describes the CRNA anesthesia service as being furnished without physician medical direction for anesthesia billing purposes. Other supervision, facility, or state requirements may still apply.