Anesthesia Medical direction guidelines.

Criteria for Medical Direction

Anesthesiologists can be reimbursed for the personal medical direction (as distinguished from supervision) that they furnish to CRNAs.

Medical direction services personally performed by an anesthesiologist will be reimbursed only if the anesthesiologist:

• Performs a pre-anesthetic examination and evaluation;

• Prescribes the anesthesia plan;

• Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence (if applicable);

• Ensures that any procedures in the anesthesia plan that he/she does not perform are performed by a qualified individual;

• Monitors the course of anesthesia administration at frequent intervals;

• Remains physically present in the surgical suite and available for immediate diagnosis and treatment of emergencies; and

• Provides indicated post-anesthesia care.

If anesthesiologists are in a group practice, one physician member may provide the preanesthesia examination and evaluation, and another may fulfill the other criteria. 

Similarly, one physician member of the group may provide post anesthesia care, while another member of the group provides the other component parts of anesthesia services. However, the medical record must indicate that physicians provided the services and identify the physicians who rendered them.

MHCP will reimburse anesthesiologists for supervision of residents per Medicare’s formula and restrictions. The teaching physician must be present during induction, emergence, and during all critical portions of the procedure, and immediately available to provide services during the entire procedure. 

The documentation in the medical records must indicate the teaching anesthesiologist’s presence or participation in the administration of the anesthesia. The teaching physician’s presence is not required during the pre-operative or post-operative visits with the recipient. 

MHCP follows Medicare guidelines for reimbursement to anesthesiologists for the supervision of residents. MHCP does not reimburse for anesthesia assistants or interns.

Pre and post anesthetic service and eligible providers

Pre-anesthetic Evaluations and Post-operative Visits

MHCP uses the CMS list of base values, which were adopted from the relative base values established by the ASA. The base value for anesthesia services includes usual pre-operative and post-operative visits. No separate payment is allowed for the pre-anesthetic evaluation regardless of when it occurs unless the recipient is not induced with anesthesia because of a cancellation of the surgery. 

If an anesthetic is not administered due to a cancellation of the surgery, the anesthesiologist or the independent CRNA may bill an E/M CPT code that demonstrates the level of service performed.

Eligible Providers

Anesthesiologists (MDA) Certified Registered Nurse Anesthetist (CRNA). CRNAs must enroll and sign a provideragreement in order to be eligible for reimbursement.

Physicians (MDs) under limited conditions as described in the sections on conscious sedation and deep sedation.

Anesthesia provider types

Anesthesiology: The practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during and after surgery.

Anesthesiologist: A physician who specializes in anesthesiology and is board certified as an anesthesiologist.

Certified Registered Nurse Anesthetist (CRNA): An advance practice registered nurse. CRNAs are registered nurses with a baccalaureate degree who have completed an additional 24 to 36 months of training in anesthesiology in an accredited program and are certified by the Council on Certification of Nurse Anesthetists, or the Council on the Certification of Nurse Anesthetists of the American Association of Nurse Anesthetists (AANA).

Personally Performed: To be considered personally performed, the anesthesiologist may not be involved in any other procedure or duties that take him/her out of the operating room. It should be assumed that if the anesthesiologist leaves the operating room, he/she is performing other duties. If the anesthesiologist leaves the operating room to perform any other duties, the anesthesia procedure may not be billed as personally performed.

Physician: A medical doctor (MD) who is licensed to provide health services within the scope of his/her profession.

What is base unit and Time unit

Base Units

Each anesthesia code (procedure codes 00100-01999) is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing fee schedule allowances.

Anesthesia services are paid on the basis of a relative value system, which include both base and actual time units. Base units take into account the complexity, risk, and skill required to perform the service.

For the most current list of base unit values for each anesthesia procedure code can be found on the Anesthesiologist Center page on the CMS website at:

http://www.cms.hhs.gov/center/anesth.asp

Time Units

Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.

Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

For anesthesia claims, the elapsed time, in minutes, must be reported. Convert hours to minutes and enter the total minutes required for the procedure in Item 24G of the CMS-1500 claim form or electronic media claim equivalent.

Time units for physician and CRNA services - both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. The table below illustrates the conversion from minutes to units used by the carrier for

processing:

Minutes    Units 

1-2             0.1 

16-17         1.1

3                0.2

18              1.2

4-5            0.3 

19-20        1.3

6               0.4 

21             1.4

7-8           0.5 

22-23       1.5

9              0.6

24            1.6

10-11       0.7

25-26      1.7

12            0.8 

27           1.8

13-14      0.9 

28-29      1.9

15           1.0 

30           2.0

NOTE: Time Units are not recognized for CPT codes 01995 (Regional IV administration of local anesthetic agent or other medication (upper or lower extremity)) and 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration).