California Medical Bill Reviewer Certification - PowerPoint Presentation

California Medical Bill Reviewer Certification
California Medical Bill Reviewer Certification

California Medical Bill Reviewer Certification - Description

Unit 2 Official Medical Fee Schedule Module 4 Anesthesia Overview Part I Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Modifiers Basic Modifiers Physical Status Modifiers ID: 785064 Download


units anesthesia pain minutes anesthesia units minutes pain services modifiers time control unit anesthesiologist base patient circumstances reimbursement surgery

Embed / Share - California Medical Bill Reviewer Certification

Presentation on theme: "California Medical Bill Reviewer Certification"— Presentation transcript


California Medical Bill Reviewer Certification

Unit 2: Official Medical

Fee Schedule

Module 4: Anesthesia



Part I: Anesthesia

Anesthesia Guidelines

Reimbursement of Anesthesia Services


Basic Modifiers

Physical Status Modifiers

Qualifying Circumstances

Hi! In this module, you will learn about anesthesia services, how they are reimbursed, and the circumstances that can affect reimbursement.

Then, you will learn how anesthesia services are used for pain management services.

Let’s start by discussing general anesthesia guidelines and how anesthesia services are reimbursed...


What is Anesthesiology?

Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain.

Anesthesia includes the use of:

Sedative drugs

Analgesic drugs

Hypnotic drugs

Anti-emetic drugs

Respiratory drugs

Cardiovascular drugs

Anesthesia also involves:

Preoperative assessment

Intra-operative patient managementPostoperative careAutonomic, neuromuscular, cardiac, and respiratory physiology


Anesthesia Guidelines

The anesthesia section in the OMFS ranges from 00100-01999.

Anesthesia codes do not correspond one-to-one with surgery codes because multiple surgery codes may crosswalk to the same anesthesia code.



surgery codes correspond to this single anesthesia service


Single anesthesia codes correspond to multiple surgical codes because the anesthesiologist performs the same tasks for any of the arthroscopic knee services and the only variation may be time.

For example, CPT 01382 is used for anesthesia services for any arthroscopic procedure on the knee joint.


Anesthesia Services

Anesthesiologists may bill for a variety of services and methods of anesthesia.

Anesthesia Methods:

General anesthesia

Moderate sedation

Regional anesthetic

Anesthesia services include:

Pre-operative visit with the patient.

Ordering and giving medication.

Monitoring the patient’s vital signs and level of sedation.


Procedures not Separately Reimbursable

Just like other procedures, some anesthesia procedures can be billed separately, while other procedures cannot be billed separately.

Services not billed separately include:

Pre and post-operative routine visits.

Administration of fluids, including blood.

Usual monitoring services such as: EKG, temperature, blood pressure, oximetry, capnography, and mass spectrometry.

The system is automated to deny all non-invasive monitoring services billed with an anesthesia code.


Separately Reimbursable Procedures

In contrast, anesthesiologists can bill for



Some of these invasive procedures include:

Insertion of a central venous catheter

Esophageal catheter

Swan-Ganz catheter


Anesthesia Reimbursement

Anesthesiologists are reimbursed per a

base unit value

assigned to each anesthesia code and

by units of time


For up to 4 hours of service:

After 4 hours of service:

Calculations are automated but may be required in a manual pricing situation.

1 Time Unit =

15 minutes

1 Time Unit =

10 minutes

Five minutes or more is considered significant enough for the




Anesthesia Reimbursement


First 4 hours:

4 hours = 240 minutes

240 minutes/15 minutes per unit




CPT 00630: Anesthesia for lumbar spine surgery

Duration: 5 hours, 35 minutes

Base Units: 8


Remaining 1 hr, 35 minutes:

335 – 240 = 95 minutes

95 minutes/10 minutes per unit



units + 5 extra minutes

Base Units + Time Units = Total Units

8 + 16 +




What happens to the extra 5 minutes?


Anesthesia Reimbursement


Remaining time:

Base Units + Time Units = Total Units

8 + 16 +




335 – 240 = 95 minutes

95 minutes/10 minutes per unit


9 + 5 extra minutes


10 units

Remember, 5 minutes or more is considered enough for a final unit.

Therefore, we round the remaining 5 minutes of time up to count as 1 whole unit!


Anesthesia Reimbursement


1 hour, 3 minutes:

1 hour, 3 minutes = 63 minutes

60 minutes/15 minutes per unit




CPT 01202: Anesthesia for hip arthroscopy

Duration: 1 hours, 3 minutes

Base Units: 4

Base Units + Time Units = Total Units

4 + 4 =


Where did the last


minutes go?

Remember, only 5 minutes or more can be reimbursed as a final unit.

So, in this case, we round down to


minutes, or 4 units!



Part I: Anesthesia

Anesthesia Guidelines

Reimbursement of Anesthesia Services


Basic Modifiers

Physical Status Modifiers

Qualifying Circumstances

Now that you are familiar with the basics of anesthesia, let’s discuss how modifiers and extreme circumstances can alter reimbursement.

We will begin by discussing a few basic anesthesia modifiers...



As you know, each section of the OMFS has a list of modifiers that pertain to those services.

Recall that


indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition.

We will discuss the following modifiers:







See the OMFS for a complete list of modifiers!


Modifier 36


Anesthesia Procedures:

This modifier increases the basic value for these procedures to


base units. Other applicable modifiers also apply.

Procedures with a basic value of

three or less base units which:

Require endotracheal intubation for prone or other difficult positions

Require surgical field avoidance

Are performed for medical necessity

...may warrant an

additional charge.

In some instances, special circumstances warrant an increase in the basic value of specific procedures.


Modifier 47

In some instances, anesthesia is provided by a surgeon, rather than an anesthesiologist.


Anesthesia by Surgeon:

regional anesthesia provided by a surgeon.

No time units are applied.

It is important to realize that


47 should only be billed with surgical codes, not anesthesia codes.


Certified Registered

Nurse Anesthetists

Certified Registered Nurse Anesthetists (CRNA)

also administer anesthesia, although they must be under the supervision of an anesthesiologist.

To be eligible for reimbursement, the anesthesiologist must be within




range, and cannot supervise more than 2 rooms

, or administer anesthesia himself.

Both the anesthesiologist and the CRNA are reimbursed.

Lastly, the anesthesiologist must be involved in the medical direction of the patient, including pre and post-operative care.

The anesthesiologist is paid for the base units and

a reduced number of time units.

The CRNA is paid the remainder of the total reimbursement of an anesthesiologist performing the service.


Modifier 48

Modifier 48 indicates that a CRNA performed anesthesia services.


Reduced Anesthesia Value for Supervising Anesthesiologist:

Reimbursement for the supervising physician shall be for the

basic value

of the procedure plus

one unit per hour or fraction thereof for the duration of the anesthesia.

Total reimbursement to the CRNA and supervising anesthesiologist shall not exceed the listed value of the service if performed by an anesthesiologist.


Suppose Dr. Jones supervises two operating rooms with CRNAs giving anesthesia in each. He does not administer the anesthesia himself.

Certified Registered

Nurse Anesthetists

Operating Room 1

Operating Room 2

Dr. Jones


Certified Registered

Nurse Anesthetists

Operating Room 1

Operating Room 2

Dr. Jones


1 hour, 15 minutes

Base Value = 4


45 minutes

Base Value = 6


Certified Registered

Nurse Anesthetists

Operating Room 1

Operating Room 2


1 hour, 15 minutes

Base Value = 4


45 minutes

Base Value = 6

Anesthesiologist: 1 unit/hour (or fraction thereof) = 2 time units

Anesthesiologist Total = 2 + 4 = 6

75 minutes = 5 units

Total Units = 9

CRNA: 9 – 6 =

3 Units

Now you try...

How many units can be reimbursed to the anesthesiologist and the CRNA?

Anesthesiologist: 1 time unit

Anesthesiologist Total = 1 + 6 = 7

45 minutes = 3 units

Total Units = 9

CRNA: 9 – 7 =

2 Units


Physical Status Modifiers

In addition to standard modifiers, there are other modifiers, known as

physical status modifiers

, which can affect the reimbursement of anesthesia services.


Physical Status Modifiers

Anesthesia complicated by the patient’s condition may be additionally reimbursed if


supports the presence of significant disease.

These significant complications are indicated by

physical status modifiers.

While hypertension and diabetes are not considered significant enough to warrant use of the higher level physical status modifiers, conditions such as:

Congestive heart failure


Uncontrolled epilepsy





Physical Status Modifiers

The physical status modifiers and their values are:





normal, healthy patient



patient with mild systemic disease



patient with severe systemic disease



patient with severe systemic disease that is a constant threat to life



moribund patient not expected to live without the surgery



brain dead patient for harvesting



Anesthesia Reimbursement


3 hours, 25 minutes:

3 hours, 25 minutes = 205 minutes

205 minutes/15 minutes per unit



units + 10 extra minutes

CPT 01402: Anesthesia for total knee replacement

Duration: 3 hours, 25 minutes

Complication: Patient has congestive heart failure (P3: 1 unit)

Base Units: 7

Base Units + Time Units + P3 Modifier Units= Total Units

7 + 14 + 1 =



195 minutes/15 min. per unit = 13

That leaves 10 minutes remaining. So, we round up to account for 1 extra unit, for a total of 14 time units!


Physical Status Modifiers

Some providers will attach a physical status modifier to all anesthesia services, while others will only attach those with unit values greater than zero.

Either method is acceptable and the system is automated to pay the modifier.

It is the processor’s responsibility to verify that documentation justifies the addition of the payable modifiers.


Qualifying Circumstances

As you know, physical status modifiers indicate significant complications. Similarly, there are special codes that indicate other extreme circumstances


can affect the reimbursement of anesthesia services.


Qualifying Circumstances

You have probably realized that there are certain circumstances which make giving anesthesia much more difficult.

If the patient is extremely old or extremely young, the reaction to the anesthetic medications may be very different and must be monitored more closely.

Certain surgical procedures, such as cardiovascular or intracranial surgery, require lowering the blood pressure or body temperature significantly to reduce bleeding.

These circumstances are known as

qualifying circumstances,

and are billed in addition to anesthesia services.


Qualifying Circumstances

Qualifying circumstances are indicated by special codes, not modifiers.

Qualifying Circumstance codes include:

99100 – Anesthesia for patient of extreme age, under one year or over seventy.

99116 – Anesthesia complicated by utilization of total body hypothermia.

99135 – Anesthesia complicated by utilization of controlled hypotension.

99140 – Anesthesia complicated by emergency conditions (specify).


Qualifying Circumstances

It is critical that documentation support the addition of qualifying circumstances.

The age of a patient is easily verified to confirm an instance of “extreme age.”

In contrast, hypothermia can only be justified if, in the


, there is documentation stating that a hypothermia pad or blanket was placed under the patient and used to drop the body temperature.


Qualifying Circumstances

You probably realize that like other providers, anesthesiologists can incorrectly bill for certain codes.

Qualifying circumstance code


is often incorrectly billed by anesthesiologists who simply keep a patient’s hypertension under control or lower the blood pressure slightly to minimize bleeding.

99135 should only be reimbursed if documentation shows a significant reduction in the blood pressure—

at least 20 points

—for delicate surgery such as intracranial operations.




Part II: Pain Management Services

Post-operative Pain Control

Chronic Pain Control

Now that you are familiar with how anesthesia is generally used, let’s discuss how it can be used for pain management.


Pain Management Services

Pain management occurs in two distinct circumstances:

Post-operative Pain Control

Chronic Pain Control


Pain Management Services

This is because the service includes the anesthetic and all monitoring necessary to bring the patient safely through the surgery, regardless of the type of anesthetic.

If a spinal, epidural, or regional anesthetic is used for anesthesia during a surgery


of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.


Post-operative Pain Control

Post-operative Pain Control

However, if a general anesthetic is given, making the patient unconscious,


the anesthesiologist gives an epidural or regional block for post-operative pain control in addition to the anesthesia given for the surgery, it can be billed




Bob Smith is having a meniscectomy performed in his right knee.

He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with an epidural anesthetic, making him numb from the waist down, and some mild IV sedation for anxiety control.

The anesthesiologist will code her

services with 01382 for basic

value and time but will



separately for the epidural


Post-operative Pain ControlExample 1Example 2

Bob Smith is having a meniscectomy performed in his right knee.

He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with a general anesthetic because his anxiety level is so high. In addition, the anesthesiologist will insert an epidural catheter for pain control in the 24 hours following surgery.

The catheter insertion is separately

reimbursed because it is not part

of the anesthetic for the surgery.

The anesthesiologist may



01996 for pain control management

on the day of surgery.


Post-operative Pain Control

In this case, it is part of the global surgery package.

Just like other procedures, the surgeon cannot bill separately for pain control services, such as inserting a pain pump catheter, if it is performed as part of the surgery.


Chronic Pain Control

In chronic pain management, anesthesiologists that specialize in pain control may see the patient for a single or a series of injections, either into a joint or body area, or into the epidural space.

They may also employ non-injection methods of pain control such as biofeedback, physical therapy, and counseling.

Chronic Pain Control

However, the most common treatment is injection.


Chronic Pain Control

In California, like any other specialty who performs these services, these injections are billed and reimbursed as

Type of Service (TOS) 2

, which is surgery.

If these services are billed as TOS 7, which is anesthesia, the processor must

change the TOS

to reflect that this is a surgical service.


Chronic Pain Control

Anesthesiologists often used the American Society of Anesthesiologists (ASA) Relative Value Guide to bill for particular services. This reference guide lists the recommended

base values

for each procedure.

Often, anesthesiologists will mistakenly indicate the anesthesia

base value

in the units field on the bill.

Remember, the bill review system already calculates the base value associated with a procedure.


Chronic Pain Control

Unfortunately, all the above scenarios are viable possibilities.

If multiple units are billed, the processor must determine if the provider has:

performed multiple injections

billed for time units

indicated the anesthesia base value of the service in the unit field

As you can see, when reviewing bills, it is important to determine the type of units and verify that they coincide with the service provided.


Chronic Pain Control


Suppose a provider bills CPT 20610: large joint injection, for 3 units.

As a processor, you should ask, “Is he billing for 3 injections or 3 time units? Or, is this the base value?"



can verify if this represents injections of both hips and one knee, for a total of

3 injections


...or a single injection took the anesthesiologist 45 minutes, for a total of

3 time units.


Chronic Pain Control

3 Joint Injections:

left hip, right hip, & right knee

The lines are separated, and the procedures are reimbursed at multiple procedure cascade.

Left hip: 20610 x 100% of FS value

Right hip: 20610 x 50% of FS value

Right knee: 20610 x 25% of FS value

3 Injections


Chronic Pain Control

3 Time Units

Single large joint injection representing time units or ASA base value

The processor will need to change the unit field to 1 and the TOS to 2 to represent the actual service performed.

1 injection


: 20610, TOS 7, Units: 3


: 20610 x 100% of FS value TOS 2, Units: 1


Chronic Pain Control

If multiple


of injections are performed, they are reimbursed at multiple procedure cascade.

If the provider appeals the recommendation, he is educated on multiple cascade logic, which avoids duplicating reimbursement for overhead, pre-operative, and post-operative care.


62278 lumbar epidural:

100% FS

64440 injection paravertebral nerve:

50% FS

20550 trigger point injection:

25% FS


Pain Management Services

A common error in pain management occurs when providers bill for an E & M service each time the patient comes in for an injection.

Unless the provider is assessing the patient’s progress in detail, treating an additional condition, or teaching or counseling the patient


, the E/M service is included in the injection procedure payment.

If a pattern, such as weekly visits is obvious, it is


each visit was a significant, separately identifiable service


not just routine questioning about pain level.



Anesthesia: Services and Procedures

Modifiers: How basic and physical status modifiers affect reimbursement.

What constitutes qualifying circumstances.

How to calculate anesthesia reimbursements.

How post-operative pain control services are reimbursed.

How chronic pain control services are reimbursed.


Module Quiz

It’s time to check your knowledge of the concepts presented in this module.

This quiz is scored.

You must achieve a score of 80% to pass. You may attempt this quiz as many times as needed to achieve a passing score.

When finished, you may move on to the next module.


CA MBR Unit 2 Module 4 Quiz

Shom More....
By: gutsynumero
Views: 4
Type: Public

Download Section

Please download the presentation from below link :

Download - The PPT/PDF document "California Medical Bill Reviewer Certifi..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.

Try DocSlides online tool for compressing your PDF Files Try Now