1. Usual and Customary Medical Bill Reviewer Training Program
Unit 1
Module 3: Anesthesia

2. Anesthesia Part I: Anesthesia Anesthesia Guidelines
Let’s start by discussing general anesthesia guidelines and how anesthesia services are reimbursed...
Part I: Anesthesia
Anesthesia Guidelines
Reimbursement of Anesthesia Services
Modifiers:
Basic Modifiers
Physical Status Modifiers
Qualifying Circumstances

3. What 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 drugs
Analgesic drugs
Hypnotic drugs
Anti-emetic drugs
Respiratory drugs
Cardiovascular drugs
Preoperative assessment
Intra-operative patient management
Postoperative care
Autonomic, neuromuscular, cardiac, and respiratory physiology

4. Anesthesia 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 from
Anesthesia 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.

5. Anesthesia services include:
Anesthesiologists may bill for a variety of services and methods of anesthesia.
Anesthesia Methods:
Anesthesia services include:
General anesthesia
Moderate sedation
Regional anesthetic
Pre-operative visit with the patient.
Ordering and giving medication.
Monitoring the patient’s vital signs and level of sedation.

6. Anesthesia Injections
Anesthesia injections are drugs ending with the suffix "-caine" (i.e.,
lidocaine, marcaine). Charges for local infiltration, metacarpal/digital block, and
topical anesthesia are considered part of surgical procedures.
Marcaine
Novocaine
Lidocaine

7. 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
(edit U001) these non-invasive monitoring services billed with an anesthesia code.

8. Separately 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

9. Anesthesia 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 minutes
After 4 hours of service:
1 Time Unit = 10 minutes
Calculations 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…

10. Anesthesia Reimbursement
CPT 01202: Anesthesia for hip arthroscopy
Duration: 1 hours, 3 minutes
Base Units: 4
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!
TIME UNITS:
1 hour, 3 minutes:
1 hour, 3 minutes = 63 minutes
60 minutes/15 minutes per unit
= 4 units
Base Units + Time Units = Total Units
4 + 4 = 8

11. Anesthesia Reimbursement
CPT : Anesthesia for ankle surgery
Duration: 5 hours, 35 minutes
Base Units: 3
What happens to the extra 5 minutes?
TIME UNITS:
First 4 hours:
TIME UNITS:
Remaining 1 hr, 35 minutes:
4 hours = 240 minutes
335 – 240 = 95 minutes
240 minutes/15 minutes per unit
95 minutes/10 minutes per unit
= 16 units
= 9 units + 5 extra minutes
Base Units + Time Units = Total Units
? = ?

12. Anesthesia 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 minutes
95 minutes/10 minutes per unit
= 10 units
= extra minutes
Base Units + Time Units = Total Units
= 29

13. Modifiers
Now that you are familiar with the basics of anesthesia, let’s discuss how extreme circumstances can alter reimbursement.
Part II: Anesthesia
Anesthesia Guidelines
Reimbursement of Anesthesia Services
Physical Status Modifiers

14. Physical 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.

15. Physical Status Modifiers
The physical status modifiers and their values are:
Modifier
Description
Unit
-P1
normal, healthy patient
-P2
patient with mild systemic disease
-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

16. 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.

17. Qualifying 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. If
billed alone, key the procedure and the system will deny the charge for the qualifying circumstance code.

18. Anesthesia 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 procedures
Now let’s take a look at multiple procedures

19. Multiple 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.

20. Services 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.

21. Unlisted Services and Procedures
Every effort should be made
to identify the service
performed with a specific
code rather than an unlisted
procedure code.
Hmm, which code should I use?
As you know, providers
often misuse the unlisted
code when a more
appropriate code is
available.

22. Unlisted Services and Procedures
Unlisted Service or Procedure Codes. Example: 01999
If 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.

23. Appendix 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/Head
Anesthesia/Neck
Anesthesia/Thorax (Chest Wall and Shoulder Girdle)
Anesthesia/Intrathoracic
Anesthesia/Spine and Spinal Cord
Anesthesia/Shoulder and Axilla
Anesthesia/Upper Abdomen
Anesthesia/Lower Abdomen
Anesthesia/Perineum
Anesthesia/Pelvis (Except Hip)
Anesthesia/Upper Leg (Except Knee)
Anesthesia/Knee and Popliteal Area
Anesthesia/Lower Leg (Below Knee, Includes Ankle and Foot)
Anesthesia/Burn Excisons or Debridement
Anesthesia/Obstetric
Anesthesia/Other Procedures
Anesthesia/Upper Arm and Elbow
Anesthesia/Forearm, Wrist, and Hand
Anesthesia/Radiological Procedures

24. Summary Great Job! Anesthesia: Services and Procedures
How to calculate anesthesia reimbursements.
Modifiers: How physical status modifiers affect reimbursement.
Unlisted Procedures: Determine when
unlisted codes should be exchanged for
listed codes.