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Provided by Coventry Health Care® ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission.

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Presentation on theme: "Provided by Coventry Health Care® ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission."— Presentation transcript:

1 Provided by Coventry Health Care® ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Usual and Customary Medical Bill Reviewer Training Program Unit 1 Module 3: Anesthesia

2 Usual & Customary Training - Anesthesia July 2011 Anesthesia Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Modifiers: Basic Modifiers Physical Status Modifiers Qualifying Circumstances Lets start by discussing general anesthesia guidelines and how anesthesia services are reimbursed...

3 Usual & Customary Training - Anesthesia July 2011 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 management Postoperative care Autonomic, neuromuscular, cardiac, and respiratory physiology

4 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 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 patients vital signs and level of sedation.

6 Usual & Customary Training - Anesthesia July 2011 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.

7 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 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 Five minutes or more is considered significant enough for the final unit. Calculations are automated but may require a manual pricing situation. Lets take a look…

10 Usual & Customary Training - Anesthesia July 2011 Anesthesia 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 = 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!

11 Usual & Customary Training - Anesthesia July 2011 Anesthesia Reimbursement TIME UNITS: First 4 hours: 4 hours = 240 minutes 240 minutes/15 minutes per unit = 16 units CPT : Anesthesia for ankle surgery Duration: 5 hours, 35 minutes Base Units: 3 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 ? = ? What happens to the extra 5 minutes?

12 Usual & Customary Training - Anesthesia July 2011 Anesthesia Reimbursement TIME UNITS: Remaining time: Base Units + Time Units = Total Units = – 240 = 95 minutes 95 minutes/10 minutes per unit = 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! The final answer is…..

13 Usual & Customary Training - Anesthesia July 2011 Modifiers Part II: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Now that you are familiar with the basics of anesthesia, lets discuss how extreme circumstances can alter reimbursement. Physical Status Modifiers

14 Usual & Customary Training - Anesthesia July 2011 Physical Status Modifiers Anesthesia complicated by the patients 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 Usual & Customary Training - Anesthesia July 2011 Physical Status Modifiers The physical status modifiers and their values are: ModifierDescriptionUnit -P1normal, healthy patient 0 -P2patient with mild systemic disease 0 -P3patient with severe systemic disease 1 -P4patient with severe systemic disease that is a constant threat to life 2 -P5moribund patient not expected to live without the surgery 3 -P6brain dead patient for harvesting 0

16 Usual & Customary Training - Anesthesia July 2011 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 processors responsibility to verify that documentation justifies the addition of the payable modifiers.

17 Usual & Customary Training - Anesthesia July 2011 Qualifying Circumstances ( ) 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, 00836) 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 conditionsusually 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 Usual & Customary Training - Anesthesia July 2011 Anesthesia by Surgeon (Modifier 47) Now lets take a look at multiple procedures 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

19 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 Unlisted Services and Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure code. As you know, providers often misuse the unlisted code when a more appropriate code is available. Hmm, which code should I use?

22 Usual & Customary Training - Anesthesia July 2011 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. Unlisted Services and Procedures 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. Unlisted Service or Procedure Codes. Example: 01999

23 Usual & Customary Training - Anesthesia July 2011 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 Usual & Customary Training - Anesthesia July 2011 Summary Anesthesia: Services and Procedures Modifiers: How physical status modifiers affect reimbursement. How to calculate anesthesia reimbursements. Unlisted Procedures: Determine when unlisted codes should be exchanged for listed codes. Great Job!


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