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

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

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

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 00100-01999 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 01464 is used for anesthesia services for any arthroscopic procedure on the ankle joint.

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.

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

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.

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

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…

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

Anesthesia Reimbursement CPT 01464: 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 3 + 16 + ? = ?

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 = 9 + 5 extra minutes Base Units + Time Units = Total Units 3 + 16 + 10 = 29

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

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.

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

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.

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. 99100 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). 99116 Anesthesia complicated by utilization of total body hypothermia (List separately, in addition to code for primary anesthesia procedure) 99135 Anesthesia complicated by utilization of controlled hypotension (List separately, in addition to code for primary anesthesia procedure) 99140 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.

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 09947. (This does not include local anesthesia.) Modifier 47 or procedure code 09947 would not be used as a modifier for anesthesia procedures 00100-01999. Now let’s take a look at multiple procedures

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.

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 (00100-00222) Neck (00300-00352) Thorax - Chest Wall and Shoulder Girdle (00400-00474) Intrathoracic (00500-00580) Spine and Spinal Cord (00600-00670). Remember, unusual forms of monitoring (eg, intra-arterial, central venous, and Swan-Ganz) are not included in anesthesia procedures.

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.

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.

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 00100-00222 Anesthesia/Neck 00300-00352 Anesthesia/Thorax (Chest Wall and Shoulder Girdle) 00400-00474 Anesthesia/Intrathoracic 00500-00580 Anesthesia/Spine and Spinal Cord 00600-00670 Anesthesia/Shoulder and Axilla 01610-01682 Anesthesia/Upper Abdomen 00700-00797 Anesthesia/Lower Abdomen 00800-00882 Anesthesia/Perineum 00902-00952 Anesthesia/Pelvis (Except Hip) 01112-01190 Anesthesia/Upper Leg (Except Knee) 01200-01274 Anesthesia/Knee and Popliteal Area 01320-01444 Anesthesia/Lower Leg (Below Knee, Includes Ankle and Foot) 01462-01522 Anesthesia/Burn Excisons or Debridement 01951-01953 Anesthesia/Obstetric 01958-01969 Anesthesia/Other Procedures 01990-01999 Anesthesia/Upper Arm and Elbow 01710-01782 Anesthesia/Forearm, Wrist, and Hand 01810-01860 Anesthesia/Radiological Procedures 01905-01933

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.