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 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.
Slide1
California Medical Bill Reviewer Certification
Unit 2: Official Medical
Fee Schedule
Module 4: Anesthesia
Slide2Overview
Part I: Anesthesia
Anesthesia Guidelines
Reimbursement of Anesthesia Services
Modifiers:
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...
Slide3What 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
Slide4Anesthesia 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.
Therefore,
17
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.
Slide5Anesthesia 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.
Slide6Procedures 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.
Slide7Separately Reimbursable Procedures
In contrast, anesthesiologists can bill for
invasive
procedures.
Some of these invasive procedures include:
Insertion of a central venous catheter
Esophageal catheter
Swan-Ganz catheter
Slide8Anesthesia 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
final
unit.
Slide9Anesthesia Reimbursement
TIME UNITS:
First 4 hours:
4 hours = 240 minutes
240 minutes/15 minutes per unit
=
16
units
CPT 00630: Anesthesia for lumbar spine surgery
Duration: 5 hours, 35 minutes
Base Units: 8
TIME UNITS:
Remaining 1 hr, 35 minutes:
335 – 240 = 95 minutes
95 minutes/10 minutes per unit
=
9
units + 5 extra minutes
Base Units + Time Units = Total Units
8 + 16 +
?
=
?
What happens to the extra 5 minutes?
Slide10Anesthesia Reimbursement
TIME UNITS:
Remaining time:
Base Units + Time Units = Total Units
8 + 16 +
10
=
34
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!
Slide11Anesthesia Reimbursement
TIME UNITS:
1 hour, 3 minutes:
1 hour, 3 minutes = 63 minutes
60 minutes/15 minutes per unit
=
4
units
CPT 01202: Anesthesia for hip arthroscopy
Duration: 1 hours, 3 minutes
Base Units: 4
Base Units + Time Units = Total Units
4 + 4 =
8
Where did the last
3
minutes go?
Remember, only 5 minutes or more can be reimbursed as a final unit.
So, in this case, we round down to
60
minutes, or 4 units!
Slide12Modifiers
Part I: Anesthesia
Anesthesia Guidelines
Reimbursement of Anesthesia Services
Modifiers:
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...
Slide13Modifiers
As you know, each section of the OMFS has a list of modifiers that pertain to those services.
Recall that
modifiers
indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition.
We will discuss the following modifiers:
Modifier
36
Modifier
47
Modifier
48
See the OMFS for a complete list of modifiers!
Slide14Modifier 36
36
Anesthesia Procedures:
This modifier increases the basic value for these procedures to
four
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.
Slide15Modifier 47
In some instances, anesthesia is provided by a surgeon, rather than an anesthesiologist.
47
Anesthesia by Surgeon:
regional anesthesia provided by a surgeon.
No time units are applied.
It is important to realize that
Modifier
47 should only be billed with surgical codes, not anesthesia codes.
Slide16Certified 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
hearing
and
visual
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.
Slide17Modifier 48
Modifier 48 indicates that a CRNA performed anesthesia services.
48
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
Slide19Certified Registered
Nurse Anesthetists
Operating Room 1
Operating Room 2
Dr. Jones
Duration:
1 hour, 15 minutes
Base Value = 4
Duration:
45 minutes
Base Value = 6
Slide20Certified Registered
Nurse Anesthetists
Operating Room 1
Operating Room 2
Duration:
1 hour, 15 minutes
Base Value = 4
Duration:
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
Slide21Physical Status Modifiers
In addition to standard modifiers, there are other modifiers, known as
physical status modifiers
, which can affect the reimbursement of anesthesia services.
Slide22Physical Status Modifiers
Anesthesia complicated by the patient’s condition may be additionally reimbursed if
documentation
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
Emphysema
Uncontrolled epilepsy
...are
reimbursable
.
Slide23Physical Status Modifiers
The physical status modifiers and their values are:
Modifier
Description
Unit
P1
normal, healthy patient
0
P2
patient with mild systemic disease
0
P3
patient with severe systemic disease
1
P4
patient with severe systemic disease that is a constant threat to life
2
P5
moribund patient not expected to live without the surgery
3
P6
brain dead patient for harvesting
0
Slide24Anesthesia Reimbursement
TIME UNITS:
3 hours, 25 minutes:
3 hours, 25 minutes = 205 minutes
205 minutes/15 minutes per unit
=
13
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 =
22
Remember,
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!
Slide25Physical 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.
Slide26Qualifying Circumstances
As you know, physical status modifiers indicate significant complications. Similarly, there are special codes that indicate other extreme circumstances
that
can affect the reimbursement of anesthesia services.
Slide27Qualifying 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.
Slide28Qualifying 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).
Slide29Qualifying 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
report
, there is documentation stating that a hypothermia pad or blanket was placed under the patient and used to drop the body temperature.
Slide30Qualifying Circumstances
You probably realize that like other providers, anesthesiologists can incorrectly bill for certain codes.
Qualifying circumstance code
99135
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.
Slide31Pain
Management
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.
Slide32Pain Management Services
Pain management occurs in two distinct circumstances:
Post-operative Pain Control
Chronic Pain Control
Slide33Pain 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
instead
of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.
Slide34Post-operative Pain Control
Post-operative Pain Control
However, if a general anesthetic is given, making the patient unconscious,
and
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
separately
.
Slide35Bob 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
not
bill
separately for the epidural
insertion.
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
not
bill
01996 for pain control management
on the day of surgery.
Slide36Post-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.
Slide37Chronic 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.
Slide38Chronic 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.
Slide39Chronic 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.
Slide40Chronic 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.
Slide41Chronic Pain Control
Example
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?"
Only
documentation
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.
Slide42Chronic 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
Slide43Chronic 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
Billed
: 20610, TOS 7, Units: 3
Paid
: 20610 x 100% of FS value TOS 2, Units: 1
Slide44Chronic Pain Control
If multiple
types
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.
Example:
62278 lumbar epidural:
100% FS
64440 injection paravertebral nerve:
50% FS
20550 trigger point injection:
25% FS
Slide45Pain 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
extensively
, the E/M service is included in the injection procedure payment.
If a pattern, such as weekly visits is obvious, it is
unlikely
each visit was a significant, separately identifiable service
and
not just routine questioning about pain level.
Slide46Summary
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.
Slide47Module 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.
Slide48CA MBR Unit 2 Module 4 Quiz