Presentation on theme: "Usual and Customary Medical Bill Reviewer Training Program"— Presentation transcript:
1Usual and Customary Medical Bill Reviewer Training Program Unit 1Module 3: Anesthesia
2Anesthesia Part I: Anesthesia Anesthesia Guidelines Let’s start by discussing general anesthesia guidelines and how anesthesia services are reimbursed...Part I: AnesthesiaAnesthesia GuidelinesReimbursement of Anesthesia ServicesModifiers:Basic ModifiersPhysical Status ModifiersQualifying Circumstances
3What is Anesthesiology? Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain.Anesthesia includes the use of:Anesthesia also involves:Sedative drugsAnalgesic drugsHypnotic drugsAnti-emetic drugsRespiratory drugsCardiovascular drugsPreoperative assessmentIntra-operative patient managementPostoperative careAutonomic, neuromuscular, cardiac, and respiratory physiology
4Anesthesia Guidelines Anesthesia procedure codes are separate, five-digit procedure codes assigned only to the administration of anesthesia. A general procedure number is given within each category, followed by exceptions or specific listings.The anesthesia section in the CPT ranges fromAnesthesia codes do not correspond one-to-one with surgery codes because multiple surgery codes may crosswalk to the same anesthesia code.Single anesthesia codes correspond to multiple surgical codes because the anesthesiologist performs the same tasks for many of the ankle procedure services and the only variation may be time.For example, CPT is used for anesthesia services for any arthroscopic procedure on the ankle joint.
5Anesthesia services include: Anesthesiologists may bill for a variety of services and methods of anesthesia.Anesthesia Methods:Anesthesia services include:General anesthesiaModerate sedationRegional anestheticPre-operative visit with the patient.Ordering and giving medication.Monitoring the patient’s vital signs and level of sedation.
6Anesthesia Injections Anesthesia injections are drugs ending with the suffix "-caine" (i.e.,lidocaine, marcaine). Charges for local infiltration, metacarpal/digital block, andtopical anesthesia are considered part of surgical procedures.MarcaineNovocaineLidocaine
7Procedures 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(edit U001) these non-invasive monitoring services billed with an anesthesia code.
8Separately Reimbursable Procedures In contrast, anesthesiologists can bill for invasive procedures.Some of these invasive procedures include:Insertion of a central venous catheterEsophageal catheterSwan-Ganz catheter
9Anesthesia Reimbursement Usual and Customary total anesthesia values are calculated by adding the separately listed basic value and the time value. Anesthesia units are keyed into the Unit field in Bill Review.For up to 4 hours of service:1 Time Unit = 15 minutesAfter 4 hours of service:1 Time Unit = 10 minutesCalculations are automated but may require a manual pricing situation.Five minutes or more is considered significant enough for the final unit.Let’s take a look…
10Anesthesia Reimbursement CPT 01202: Anesthesia for hip arthroscopyDuration: 1 hours, 3 minutesBase Units: 4Where 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!TIME UNITS:1 hour, 3 minutes:1 hour, 3 minutes = 63 minutes60 minutes/15 minutes per unit= 4 unitsBase Units + Time Units = Total Units4 + 4 = 8
11Anesthesia Reimbursement CPT : Anesthesia for ankle surgeryDuration: 5 hours, 35 minutesBase Units: 3What happens to the extra 5 minutes?TIME UNITS:First 4 hours:TIME UNITS:Remaining 1 hr, 35 minutes:4 hours = 240 minutes335 – 240 = 95 minutes240 minutes/15 minutes per unit95 minutes/10 minutes per unit= 16 units= 9 units + 5 extra minutesBase Units + Time Units = Total Units? = ?
12Anesthesia Reimbursement 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!The final answer is…..TIME UNITS:Remaining time:335 – 240 = 95 minutes95 minutes/10 minutes per unit= 10 units= extra minutesBase Units + Time Units = Total Units= 29
13ModifiersNow that you are familiar with the basics of anesthesia, let’s discuss how extreme circumstances can alter reimbursement.Part II: AnesthesiaAnesthesia GuidelinesReimbursement of Anesthesia ServicesPhysical Status Modifiers
14Physical 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 failureEmphysemaUncontrolled epilepsy...are reimbursable.
15Physical Status Modifiers The physical status modifiers and their values are:ModifierDescriptionUnit-P1normal, healthy patient-P2patient with mild systemic disease-P3patient with severe systemic disease1-P4patient with severe systemic disease that is a constant threat to life2-P5moribund patient not expected to live without the surgery3-P6brain dead patient for harvesting
16Physical 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.
17Qualifying Circumstances (99100-99140) In some situations, unusual risk may entitle the physician to additional modifying units. Referred to as qualifying circumstances, these are reported as additional procedure numbers. The following valid codes may be keyed into the system.Anesthesia for patient of extreme age under one year or over seventy (List separately, in addition to code for primary anesthesia procedure). (For procedures performed on infants less than 1 year of age at time of surgery, see 00326, 00561, 00834, ).Anesthesia complicated by utilization of total body hypothermia (List separately, in addition to code for primary anesthesia procedure)Anesthesia complicated by utilization of controlled hypotension (List separately, in addition to code for primary anesthesia procedure)Anesthesia complicated by emergency conditions—usually when a delay in treatment would lead to an increase in the threat to life/body part (List separately, in addition to code for primary anesthesia procedure)Keep in mind, these codes should never be billed alone; they should always be billed with an anesthesia code. Ifbilled alone, key the procedure and the system will deny the charge for the qualifying circumstance code.
18Anesthesia by Surgeon (Modifier 47) Regional or general anesthesia provided by a surgeon may be reported by adding modifier 47 to the basic service or by use of the separate, five-digit modifier code (This does not include local anesthesia.) Modifier 47 or procedure code would not be used as a modifier for anesthesia proceduresNow let’s take a look at multiple procedures
19Multiple Anesthesia Procedures When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported. The time reported is the combined total for all procedures.When two anesthesia procedures are billed for the same date of service, the system will recommend payment for the procedure with the highest value, and will deny the charges for any remaining anesthesia procedures billed.
20Services Included in Anesthesia Procedures Services included in Anesthesia are usual preoperative and postoperative visits, the anesthesia care during the procedure and the administration of fluids. In addition to administration of blood and the usual monitoring services such as… ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry.Further processing guidelines can be followed using the narrative/suspense instructions for each category of procedures. As an example… Head ( ) Neck ( ) Thorax - Chest Wall and Shoulder Girdle ( ) Intrathoracic ( ) Spine and Spinal Cord ( ).Remember, unusual forms of monitoring (eg, intra-arterial, central venous,and Swan-Ganz) are not included in anesthesia procedures.
21Unlisted Services and Procedures Every effort should be madeto identify the serviceperformed with a specificcode rather than an unlistedprocedure code.Hmm, which code should I use?As you know, providersoften misuse the unlistedcode when a moreappropriate code isavailable.
22Unlisted Services and Procedures Unlisted Service or Procedure Codes. Example: 01999If the necessity of the services has been verified, and the service authorized, additional information may be requested about the procedure, or an online search may be performed.Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure.The unlisted code billed may represent a slightly different version of an established code which would still be appropriate.
23Appendix A: Categories and Subcategories for Anesthesia Codes There are several categories and subcategories of Anesthesia procedures, the CPT codes available for reporting Anesthesia services are listed as follows:Anesthesia/HeadAnesthesia/NeckAnesthesia/Thorax (Chest Wall and Shoulder Girdle)Anesthesia/IntrathoracicAnesthesia/Spine and Spinal CordAnesthesia/Shoulder and AxillaAnesthesia/Upper AbdomenAnesthesia/Lower AbdomenAnesthesia/PerineumAnesthesia/Pelvis (Except Hip)Anesthesia/Upper Leg (Except Knee)Anesthesia/Knee and Popliteal AreaAnesthesia/Lower Leg (Below Knee, Includes Ankle and Foot)Anesthesia/Burn Excisons or DebridementAnesthesia/ObstetricAnesthesia/Other ProceduresAnesthesia/Upper Arm and ElbowAnesthesia/Forearm, Wrist, and HandAnesthesia/Radiological Procedures
24Summary Great Job! Anesthesia: Services and Procedures How to calculate anesthesia reimbursements.Modifiers: How physical status modifiers affect reimbursement.Unlisted Procedures: Determine whenunlisted codes should be exchanged forlisted codes.