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

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

1 ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® Arizona Medical Bill Reviewer Training Program Unit 1: Professional Services Module 2: Anesthesia Guidelines

2 2 Arizona Regulation Training – Anesthesia Overview Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Physical Status Modifiers Pain Management 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. Lets start by discussing general anesthesia guidelines and how anesthesia services are reimbursed... Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services

3 3 Arizona Regulation Training – Anesthesia 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 4 Arizona Regulation Training – Anesthesia Anesthesia Guidelines 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. Therefore, 18 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 is used for anesthesia services for any arthroscopic procedure on the knee joint.

5 5 Arizona Regulation Training – Anesthesia Anesthesia Time Anesthesia time begins: – when an anesthesiologist or certified registered nurse anesthetist (CRNA) physically starts to prepare the patient for the induction of anesthesia in the operating room (or its equivalent). And ends: – when the anesthesiologist is no longer in constant attendance (when the patient is safely put under postoperative supervision).

6 6 Arizona Regulation Training – Anesthesia 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.

7 7 Arizona Regulation Training – Anesthesia Special Coding Situations Special coding situations such as those involving multiple procedures, additional procedures, unusual monitoring, prolonged physician services, postoperative pain management, monitored (stand- by anesthesia), invasive anesthesia and chronic pain management services require application of the fee schedule in a manner consistent with guidelines of the ASA.

8 8 Arizona Regulation Training – Anesthesia 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.

9 9 Arizona Regulation Training – Anesthesia 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

10 10 Arizona Regulation Training – Anesthesia Anesthesia Reimbursement The system will recommend payment for anesthesia services based on the published conversion factors. Base value units + Time units (plus additional modifying units, when modifier is keyed) = Total Units Total Units x Conversion Factor ($55.83) = Total Fee 1 time unit is equal to 15 minutes for anesthesia time or any 7 minute portion thereof.

11 11 Arizona Regulation Training – Anesthesia Anesthesia Reimbursement Anesthesiologists and CRNAs are reimbursed per a base unit value assigned to each anesthesia code and by units of time. Calculations are automated but may be required in a manual pricing situation. 1 Time Unit = 15 minutes Lets take a look…

12 12 Arizona Regulation Training – Anesthesia Anesthesia Reimbursement TIME UNITS: 5 hours (300 minutes/15 minutes per unit) = 20 units 37 minutes/15 minutes per unit = 3 units Total units = 23 CPT 00630: Anesthesia for lumbar spine surgery Duration: 5 hours, 37 minutes Base Units: 8 Base Units + Time Units = Total Units = 31

13 13 Arizona Regulation Training – Anesthesia 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 hour, 3 minutes Base Units: 4 Base Units + Time Units = Total Units = 8 Where did the last 3 minutes go? Remember, only round up when 7 minutes or more. So, in this case, it is 60 minutes or 4 units!

14 14 Arizona Regulation Training – Anesthesia Modifiers Each section of the Official Medical Fee Schedule (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 23 Modifier 47 See the OMFS for a complete list of modifiers!

15 15 Arizona Regulation Training – Anesthesia Modifier Anesthesia Procedures: This modifier pays 125% of the OMFS value. 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.

16 16 Arizona Regulation Training – Anesthesia Modifier 47 In some instances, anesthesia is provided by a surgeon, rather than an anesthesiologist. When submitted with a 47 modifier, it is recommended for payment at 50% of the calculated anesthesia relative value. 47 Anesthesia by Surgeon: regional anesthesia provided by a surgeon. No time units are applied. This pays the lesser of charge or OMFS value. It is important to realize that Modifier 47 should only be billed with surgical codes, not anesthesia codes.

17 17 Arizona Regulation Training – Anesthesia Certified Registered Nurse Anesthetists Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, although they must be under the supervision of an anesthesiologist. Certified Registered Nurse Anesthetists (CRNAs), will be reimbursed at the same rate as all other health care professionals when performing, coding and billing for the same services. Key codes and charges as billed.

18 18 Arizona Regulation Training – Anesthesia Physical Status Modifiers Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Pain Management Now that you are familiar with the basics of anesthesia, lets discuss how extreme circumstances can alter reimbursement. Physical Status Modifiers

19 19 Arizona Regulation Training – Anesthesia 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.

20 20 Arizona Regulation Training – Anesthesia Physical Status Modifiers The physical status modifiers and their values are: ModifierDescriptionUnit P3Patient with severe systemic disease 1 P4Patient with severe systemic disease that is a constant threat to life 2 P5A moribund patient not expected to live without the operation 3

21 21 Arizona Regulation Training – Anesthesia 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.

22 22 Arizona Regulation Training – Anesthesia Qualifying Circumstances Lets take a look… 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.

23 23 Arizona Regulation Training – Anesthesia 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.

24 24 Arizona Regulation Training – Anesthesia Qualifying Circumstances Qualifying circumstances are indicated by special codes, not modifiers. Qualifying Circumstance codes include: – Anesthesia for patient of extreme age, under one year or over seventy – Anesthesia complicated by utilization of total body hypothermia – Anesthesia complicated by utilization of controlled hypotension – Anesthesia complicated by emergency conditions (specify).

25 25 Arizona Regulation Training – Anesthesia Qualifying Circumstances CPT CODE DescriptionUnit Anesthesia for patient of extreme age, under one year or over seventy Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypotension Anesthesia complicated by emergency conditions (specify). 2

26 26 Arizona Regulation Training – Anesthesia 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 report, there is documentation stating that a hypothermia pad or blanket was placed under the patient and used to drop the body temperature.

27 27 Arizona Regulation Training – Anesthesia 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 patients hypertension under control or lower the blood pressure slightly to minimize bleeding should only be reimbursed if documentation shows a significant reduction in the blood pressureat least 20 pointsfor delicate surgery such as intracranial operations.

28 28 Arizona Regulation Training – Anesthesia Pain Management Part II: Pain Management Services Post-operative Pain Control Chronic Pain Control Now that you are familiar with how anesthesia is generally used, lets discuss how it can be used for pain management. Part II: Pain Management Services Post-operative Pain Control Chronic Pain Control

29 29 Arizona Regulation Training – Anesthesia Pain Management Services Pain management occurs in two distinct circumstances: Lets take a look… Post-operative Pain Control Chronic Pain Control

30 30 Arizona Regulation Training – Anesthesia 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 instead of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.

31 31 Arizona Regulation Training – Anesthesia 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.

32 32 Arizona Regulation Training – Anesthesia 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 for basic value and time but will not bill separately for the epidural insertion. Post-operative Pain Control Example 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 for pain control management on the day of surgery.

33 33 Arizona Regulation Training – Anesthesia 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.

34 34 Arizona Regulation Training – Anesthesia 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.

35 35 Arizona Regulation Training – Anesthesia Chronic Pain Control 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.

36 36 Arizona Regulation Training – Anesthesia 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.

37 37 Arizona Regulation Training – Anesthesia 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.

38 38 Arizona Regulation Training – Anesthesia Chronic 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. Lets take a look…

39 39 Arizona Regulation Training – Anesthesia 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: x 100% of FS value Right hip: x 50% of FS value Right knee: x 50% of FS value 3 Injections

40 40 Arizona Regulation Training – Anesthesia 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 Billed: 20610, TOS 7, Units: 3 Paid: x 100% of FS value TOS 2, Units: 1

41 41 Arizona Regulation Training – Anesthesia Chronic 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: lumbar epidural: 100% FS injection paravertebral nerve: 50% FS trigger point injection: 50% FS

42 42 Arizona Regulation Training – Anesthesia 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 patients 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.

43 43 Arizona Regulation Training – Anesthesia Summary Anesthesia: Services and Procedures Modifiers: How physical status modifiers affect reimbursement. How to calculate anesthesia reimbursements. How post-operative pain control services are reimbursed. How chronic pain control services are reimbursed.


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