will peroperative assement inculsive in anesthesia billing? Citations:

Preoperative assessment is included in the payment for the anesthesia services, per the National Correct Coding Initiative (NCCI).

HCPCS/CPT® codes include all services usually performed as part of the procedure as a standard of medical/surgical practice.  A physician should not separately report these services simply because HCPCS/CPT® codes exist for them.

1. The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post- anesthesia recovery care. Preoperative evaluation includes a sufficient history and physical examination so that the risk of adverse reactions can be minimized, alternative approaches to anesthesia planned, and all questions answered.

2. Anesthesia services include, but are not limited to, preoperative evaluation of the patient, administration of anesthetic, other medications, blood, and fluids, monitoring of physiological parameters, and other supportive services.

3. It is standard medical practice for an anesthesia practitioner to perform a patient examination and evaluation prior to surgery.  This is considered part of the anesthesia service and is included in the base unit of the anesthesia code.

The evaluation and examination are not reported in the anesthesia time.  If surgery is canceled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an evaluation and management service and the appropriate E&M code (usually a consultation code) may be reported.  (A non-medically directed CRNA may also report an E&M code under these circumstances if permitted by state law.)

Anesthesia cpt code procedure qualifiying factor and description units.

Procedure Codes and Modifiers

Anesthesia providers are required to utilize the appropriate anesthesia code identified in the current Relative Value Guide published by the American Society of Anesthesiologists. Time in attendance should be billed by listingtotal minutes

HP will calculate total units by dividing the total minutes (reported in block 24G) by 15, rounding up to the next whole number, and adding the time units to the auto-loaded base unit values. The base unit values are derived from the ASARVG for CPT-4 anesthesia codes. 

Of anesthesia time in block 24G of the CMS-1500 claim form. Type of service “7” should be used for billing anesthesia codes (00100- 01997). The (837) Institutional electronic claim and the paper claim have been modified to accept up to four Procedure Code Modifiers. Effective

October 1, 2004 to bill for code 90784, bill the first line item with the code and one unit. Bill the second line item with code 90784 with modifier 76 (repeat procedure) and 3 units.

The number of qualifying factor units is multiplied by the price allowed for anesthesia services. For more information regarding qualifying factors, see the next section of this manual.

Qualifying Factors

Beginning June 14, 2002, qualifying factors will be reimbursable. Qualifying factors allow for anesthesia services provided under complicated situations depending on irregular factors (ex: abnormal risk factors, significant operative conditions). The qualifying procedures would be reported in conjunction with the anesthesia procedure code on a separate line item using 1 unit of service.

The qualifying procedure codes are indicated below.

Procedure Code Description Units

99100 Anesthesia for recipient with farthest ages, over seventy and under one year 1

99116 Complication of anesthesia by utilization of total body hypothermia 1

99135 Complication of anesthesia by utilization of controlled hypotension 1

99140 Complication of anesthesia by emergency conditions 1

Anesthesia claim filing limit and copayment for anesthesia services

Time Limit for Filing Claims

Medicaid requires all claims for Anesthesiologists, CRNAs and AAs to be filed within one year of the date of service. Refer to Section 5.1.4, Filing Limits, for more information regarding timely filing limits and exceptions.

Diagnosis Codes

The International Classification of Diseases - 9th Revision - Clinical Modification (ICD-9-CM) manual lists required diagnosis codes. These manuals may be obtained by contacting the American Medical Association,

P.O. Box 10950, Chicago, IL 60610.

NOTE:

ICD-9 diagnosis codes must be listed to the highest number of digits possible (3, 4, or 5 digits). Do not use decimal points in the diagnosis code field

Cost Sharing (Copayment)

Copayment amount does not apply to services provided by Anesthesiologists, Certified Registered Nurse Anesthetists or Anesthesiology Assistants.

Teaching Anesthesiologist service - GC modifier

Anesthesia Services and Teaching Anesthesiologist

If a teaching anesthesiologist is involved in a single procedure with one resident, the anesthesia services will be paid at the personally performed rate. The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure.

The teaching physician’s physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, the anesthesiologist’s services will be paid at the medically directed rate.

Use modifier GC (Teaching Physician Service) to indicate the service has been performed in part by a resident under the direction of a teaching physician. This modifier is added after the anesthesia modifier.

Non-Covered Anesthesia Services

The following anesthesia services are non-covered: • Stand By

anesthesia billing - some specific points

Some specific points that you should be aware of Anesthesia:

* CPT coding guidelines for conscious sedation codes instruct practices not to report Codes 99143 to 99145 in conjunction with the codes listed in CPT Appendix G. NHIC will follow the National Correct Coding Initiative, which added edits in April 2006 that bundled CPT codes 99143 and 99144 into the procedures listed in Appendix G (There are no edits for code 99145; it is an add-on-code and it is not paid if the primary code is not paid.)

* In the unusual event that a second physician (other than the one performing the diagnostic or therapeutic services) provides moderate sedation in the facility setting for the procedures listed in CPT Appendix G, the second physician can bill 99148 to 99150, but cannot report these codes when the second physician performs these services (on the same day as a medical/surgical service) in the non-facility setting.

* If an anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections, and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991. In this case, the service must meet the criteria for monitored anesthesia care. 

If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.

* There is no CPT code for the performance of local anesthesia, and as such, payment for this service is considered to be part of the payment for the underlying medical or surgical service. Therefore, if the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation (such as a local or topical anesthesia), then the conscious sedation code should not be reported and the contactor will allow no payment.

When denying claims, as appropriate under this policy, contractors will use the message when the service is bundled into the other service: “Payment is included in another service received on the same day.”

Contractors will adjust claims brought to their attention that were not processed in accordance with the Medicare physician fee schedule data base indicators assigned to the conscious sedation codes. Requests for reopening may be submitted to the Written Inquiries Department in your jurisdiction.

Pain management cpt codes 62310, 62319, 64415 - 64449

Pain Management - Anesthesia

Pain Management Consultation

Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. 

However, normal postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported.

Postoperative Pain Control Procedures

When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service. Examples of such procedures include:

62310-62319           Epidural or subarchnoid injections
64415-64416           Brachial plexus injection, single or continuous
64445-64448           Sciatic or femoral injections, single or continuous
64449                       Lumbar plexus injections, continuous

These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.

NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day.

Daily Management of Continuous Pain Control Techniques

Daily hospital management of continuous epidural or subarachnoid drug administration is reported using CPT code 01996 (1 unit of service daily). This code may be reported on the first and subsequent postoperative days as medically necessary.

When continuous block codes 64416, 64446, 64448, or 64449 are reported on the day of surgery, no additional reporting of daily management is permitted during the following ten days (10 day global period). When these injections procedures constitute the main surgical anesthetic and are therefore not separately reported on the day of surgery, subsequent days’ hospital management is reported using the appropriate hospital visit code (99231-99233).

CPT codes which are not inclusive in Anesthesia billing

CPT® codes describing services that are integral to an anesthesia service include but are not limited to, the following:

•  99201-99499 (Evaluation and management)

The CPT® book, in its Anesthesia Guidelines, at the start of the Anesthesia section, states, “These services include the usual preoperative and postoperative visits….”

In a copy of a lecture presented by Dr. James Arens, posted on the ASA website, he discusses the fact that these pre-operative visits are not payable.

“For many years the preoperative visit was considered to be part of the global fee for anesthesia services based upon base units plus time. 

With the advent of preoperative anesthesia(assessment) clinics, the scope of this service has undergone drastic change. The history and past records review has become much more extensive. The evaluation of the patient and the explanation of the risk and options have also become much more detailed.

I have heard surgeons state that they are no longer "capable" of assessing patients to undergo anesthesia. Yet the ability to bill for such services is very limited. The values of a well run preoperative clinic are self-evident. However, the inability to collect for these services rendered has caused several clinics to be closed. The codes (99201-99205) for evaluation and management services are quite simple. However, reimbursement for this valuable service remains problematic.”

Summary:

It would be improper for any group to bill for preoperative anesthesia assessments.  The payment for that service is included in the payment for the anesthesia payment itself.  Any money collected for these services in the would have to be returned to the payers.  In addition, any hospital providing this service would need to review with its attorney the issue of providing financial support to a for-profit entity.

Base unit reduction in payment - anesthesia billing

Concurrent Medically Directed Procedures

Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether the other procedures overlap each other. 

Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and one Medicare patient, this represents three (3) concurrent cases.

The following example illustrates this concept and guides physicians in determining how many procedures are directed:

Procedures A through E are medically directed procedures involving CRNAs. The starting and ending times for each procedure represent the periods during which anesthesia times are counted.

Procedure A begins at 8:00AM and ends at 8:20AM

Procedure B begins at 8:10AM and ends at 8:45AM

Procedure C begins at 8:30AM and ends at 9:15AM

Procedure D begins at 9:00AM and ends at 12:00 noon

Procedure E begins at 9:10AM and ends at 9:55AM

Procedure   Number of Concurrent Medically Directed Procedures  Base Unit Reduction Percentage
A                                     2                                                                             10%
B                                     2                                                                              10%
C                                     3                                                                              25%
D                                     3                                                                              25%
E                                     3                                                                               25%

A physician who is concurrently directing the administration of anesthesia to not more than four (4) surgical patients cannot ordinarily be involved in rendering additional services to other patients.

However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients. 

It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.

However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. No fee schedule payment is made.

The examples listed above are not intended to be an exclusive list of allowed situations. It is expected that the medically-directing anesthesiologist is aware of the nature and type of services he or she is medically directing, and is personally responsible for determining whether his supervisory capacity would be diminished if he or she became involved in the performance of a procedure. It is the responsibility of this medically-directing anesthesiologist to provide services consistent with these regulations.

payment rules for anesthesia billing

Payment Rules

The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor. The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA)

(Base Units + Time Units) x Participating Conversion Factor = Allowance

• Non-Participating Physician not Medically Directing (Modifier AA) (Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK)

(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK) (Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ) (Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX) (Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

PAYMENT AND REIMBURSEMENT for anesthesia billing

PAYMENT AND REIMBURSEMENT

Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.

Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.

Payment at Medically Supervised Rate

Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. 

An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.

Payment for Multiple Anesthesia Procedures and Add-On Codes

Multiple Anesthesia Procedures

Payment may be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. 

Payment is based on the base unit of the anesthesia procedure with the highest base unit value and the total time units based on the multiple procedures with the exception of the new add-on codes. On the CMS-1500 claim form, report the anesthesia procedure code with the highest base unit value in Item 24D. In Item 24G, indicate the total time for all the procedures performed.

Add-On Codes

Add-on codes exist for anesthesia involving burn excisions or debridement and obstetrical anesthesia. The add-on code is billed in conjunction to the primary anesthesia code. In the burn area, code 01953 is used in conjunction with code 01952. In the obstetrical area, code 01968 or 01969 is used in conjunction with code 01967. 

All anesthesia time should be reported only with the primary anesthesia code involving burn excisions or debridement. Anesthesia time for the obstetrical codes should be reported separately on the primary code and the add-on code.

Anesthesia Billing and coding

Billing Instructions

Claims must be submitted on the claim Form CMS-1500 or electronic media claim equivalent.

The following are specific to anesthesia claims submission:

•Item  24D – the appropriate anesthesia modifier must be reported

•Item 24G – the actual anesthesia time, in minutes, must be reported.

Modifiers

Anesthesia modifiers must be used with anesthesia procedure codes to indicate whether the procedure was personally performed, medically directed, or medically supervised.

AA - Anesthesia services personally performed by the anesthesiologist

AD - Medical supervision by a physician; more than four concurrent anesthesia services

G8 -  Monitored anesthesia care (an informational modifier, does not affect reimbursement)

G9 -  MAC for at risk patient (an informational modifier, does not affect reimbursement)

QK -  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals

QS -  Monitored anesthesia care (an informational modifier, does not affect reimbursement)

QX -  CRNA service with medical direction by a physician

QY -  Medical direction of one CRNA by a physician

QZ -  CRNA service without medical direction by a physician

NOTE: Medicare does not recognize Physical Status P modifiers.

NOTE : Modifier QS versus Modifiers G8 or G9 should be used for Monitored Anesthesia Care.

Anesthesia provider reimbursement

Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.

Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ,

CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.

Payment at Medically Supervised Rate

Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. 

An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.

How payment calculated for Anesthesia service?

Payment Rules

The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor. The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA) (Base Units + Time Units) x Participating Conversion Factor = Allowance

• Non-Participating Physician not Medically Directing (Modifier AA) (Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK) (Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK) (Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ) (Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX) (Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

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).

Billing for Anesthesia Services

Claims Documentation Requirements

Submit claims for anesthesia services on the CMS-1500 claim form or the electronic equivalent. Use specific CPT American Society of Anesthesiology (ASA) anesthesia codes or surgical codes with the appropriate anesthesia modifier. For authorized surgical services, MHCP prefers that anesthesia services are billed using surgical procedure codes with the appropriate anesthesia modifier.

Anesthesiologists and CRNAs must comply with MHCP requirements for billing sterilization procedures. Submit a Sterilization Consent Form, signed and dated by the recipient and the physician, with anesthesia claims for sterilization procedures.

Exact Minutes

Submit the exact number of minutes from the preparation of the patient for induction to the time when the anesthesiologist or the CRNA was no longer in personal attendance or continues to be required. Enter only the number of minutes in the units box. MHCP will calculate the base units for each procedure.

Modifiers

To properly identify the exact nature of the service provided, use the following modifiers: 

Anesthesia Modifiers

AA - Anesthesia services performed personally by anesthesiologist

AD - Medical supervision by a physician: more than four concurrent anesthesia procedures

QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.

QS - Monitored anesthesia care services.

QX - CRNA service with medical direction by an anesthesiologist

QY - Anesthesiologist medically directs one CRNA

QZ - CRNA service without medical direction by an anesthesiologist

Conscious Sedation and Deep Sedation

Conscious Sedation

The intent of conscious sedation is for the patient to remain conscious and able to communicate during the entire procedure. 

The patient retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and/or verbal command. Conscious sedation includes performance and documentation of pre- and post sedation evaluations of the patient, administration of the sedation and/or analgesic agents, and monitoring of cardiorespiratory functions (pulse oximetry, cardio respiratory monitor, and blood pressure).

Conscious sedation may be administered by physicians (MDs) who have received training in moderate sedation. Follow 2006 CPT guidelines for the use of conscious sedation codes. Conscious sedation codes cannot be billed when anesthesia services are provided at the same time.

Deep Sedation

Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. 

Deep sedation may be administered by emergency medicine physicians (MDs) whose advance practice training has prepared them for airway management, advanced life support and rescue from any level of sedation.

Use the appropriate anesthesia or surgical procedure code to bill deep sedation and indicate the exact number of minutes in direct recipient contact. When deep sedation is performed by emergency medicine physicians, add modifier AA to the procedure code.

Monitored Anesthesia Care (MAC)

Monitored anesthesia care is a specific anesthesia service in which an anesthesiologist or CRNA has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.

Monitored anesthesia care includes all aspects of anesthesia care: a pre-procedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist or CRNA must be continuously physically present and provide a number of specific services, including but not limited to:

• Monitoring of vital signs, maintenance of the patient’s airway and continual evaluation of vital functions;

• Diagnosis and treatment of clinical problems that occur during the procedure;

• Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort;

• Provision of other medical services as needed to accomplish the safe completion of the procedure;

• Anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely. Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. 

If, for an extended period, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic.

Anethesia billing modifier QK, QX AND G8,G9

Medicare Part B Anesthesia Modifiers

Medicare’s coverage of anesthesia services range from the least intensive to the most intensive services and include:

1. Local or topical anesthesia - the least intense;

2. Moderate (conscious sedation);

3. Regional anesthesia; and

4. General anesthesia – monitored anesthesia care (MAC).

Medicare covers MAC when provided for services considered reasonable and necessary. Services involving the administration of anesthesia are reported by the use of a 5-digit anesthesia procedure code (00100 – 01999) along with applicable modifiers.

A surgeon or physician cannot bill for anesthesia at the same time he/she is performing surgery. The Centers for Medicare and Medicaid Services (CMS) recently published Medicare Learning Network (MLN) article MM5618 “Anesthesia Services Furnished by the Same Physician Providing the Medical and Surgical Service – Revised.” 

This article can be found in Medicare B News Issue 240, October 2, 2007 and covers conscious sedation codes 99143, 99144, 99145, 99148, 99149 and  99150. Providers who bill these codes are encouraged to review this article thoroughly.

Medically directed anesthesia services should be billed using the appropriate modifiers listed below.

•AA: Anesthesia services personally performed by an anesthesiologist.  

This modifier allows full fee schedule reimbursement.

• AD: Medical supervision by a anesthesiologist: more than 4 concurrent anesthesia procedures  Per the Internet Only Manual (IOM) Publication 100-04; Chapter 12, Section 50.D: “Carriers may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures.

An additional time unit may be recognized if the anesthesiologist can document that he or she was present at induction.”

• QK: Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals. 

This modifier limits payment to 50% of the amount that would have been allowed if personally performed by a anesthesiologist or non-supervised CRNA.

• QX: CRNA service with medical direction by a anesthesiologist.

This modifier limits payment to 50% of the amount that would have been allowed if personally performed by an anesthesiologist or non-supervised CRNA.

• QY: Anesthesiologist medically directs one CRNA. 

This modifier limits payment to anesthesiologist and CRNA to 50% of the amount that would have been allowed if personally performed by anesthesiologist.

• QZ: CRNA service without medical direction by a anesthesiologist.

This modifier has no affect on payment and the allowed amount is what would have been allowed if personally performed by an anesthesiologist.

As a reminder, the anesthesia modifiers above are pricing modifiers and must be listed in first position to insure correct reimbursement.

The modifiers below: QS, G8 and G9 modifiers are informational only and do not affect payment. Informational modifiers must be used in the second modifier position, in conjunction with a pricing anesthesia modifier in the first modifier position.

• QS: Monitored anesthesia care (MAC)

• G8: MAC for deep complex complicated or markedly invasive surgical procedures and may be used in lieu of modifier QS.

• G9: MAC for a patient who has a history of severe cardiopulmonary condition and may be used in lieu of modifier QS.

In Medicare B News Issue 246 June 24, 2008 NAS published “Anesthesia Base Rate Pricing.” This article is a good resource to help providers determine correct base and time units as well as the reimbursement formula.

Applies to the states of: AK, AZ, MT, ND, OR, SD, UT, WA & WY.