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Pennsylvania Medical Bill Reviewer Training Program
Unit 1: Professional Services
Module 2: Anesthesia
PA Regulations Training March 2010
Overview
Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia
Services Physical Status Modifiers Supervision of CRNAs 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.
Let’s start by discussing general
anesthesia guidelines and how anesthesia services are reimbursed...
Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia
Services
PA Regulations Training March 2010
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
PA Regulations Training March 2010
Anesthesia Guidelines
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.
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 01382 is used for
anesthesia services for any arthroscopic
procedure on the knee joint.
PA Regulations Training March 2010
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 patient’s vital signs
and level of sedation.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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
PA Regulations Training March 2010
Anesthesia Reimbursement
Anesthesiologists are reimbursed per a base unit value assigned to each anesthesia code and by units of time.
• Although PA Workers’ Compensation guidelines give anesthesia pricing as a 15-minute block, the system has it broken down to a per-minute value.
• Therefore, the time is keyed into the unit field per minute.
Anesthesia Conversion Factor (PA)
Example: 45 minutes of anesthesia is keyed as 45 in the unit field and the system converts that information into the appropriate payment.
PA Regulations Training March 2010
Modifiers
Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia
Services
Supervision of CRNAs Pain Management
Now that you are familiar with the
basics of anesthesia, let’s discuss how
extreme circumstances can
alter reimbursement.
Physical Status Modifiers
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
Physical Status Modifiers
The physical status modifiers and their values are:
Modifier
Description Unit
P1 normal, healthy patient 0
P2 patient with mild systemic disease 0
P3 patient with severe systemic disease 1
P4patient 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 0
PA Regulations Training March 2010
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 It is the processor’s processor’s
responsibility to responsibility to verify that verify that
documentation documentation justifies the justifies the
addition of the addition of the payable payable
modifiers.modifiers.
PA Regulations Training March 2010
Certified Registered Nurse Anesthetists
Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, often under the supervision of an anesthesiologist.
To be eligible for reimbursement, the anesthesiologist must be within hearing and visual range.
The anesthesiologist must be involved in the medical direction of the patient, including pre and post-operative care.
PA Regulations Training March 2010
Certified Registered Nurse Anesthetists
*Both the anesthesiologist and the CRNA are reimbursed*
Without supervision: the modifier –QX is applied and full payment is made at fee schedule rates.
With supervision: standard fee calculation is performed:
Base units + time + physical status modifiers x conversion factor
Then, HALF the allowable reimbursement is paid to the supervising anesthesiologist with modifier –QY and HALF is paid to the CRNA with modifier –QZ.
PA Regulations Training March 2010
Certified Registered Nurse Anesthetists
QX
QY
QZ
Recap of Modifiers
CRNA without supervision
Anesthesiologist supervision of CRNA
Supervised CRNA
PA Regulations Training March 2010
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, let’s discuss how it can be used for pain management.
Part II: Pain Management Services Post-operative Pain Control Chronic Pain Control
PA Regulations Training March 2010
Pain Management Services
Pain management occurs in two distinct circumstances:
Let’s take a look…
Post-operative Pain Control Chronic Pain Control
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
Post-operative Pain Control
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.
PA Regulations Training March 2010
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 herservices with 01382 for basic value and time but will not bill separately for the epidural insertion.
Post-operative Pain Control
Example 1 Example 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
01996 for pain control management on the day of surgery.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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.
PA Regulations Training March 2010
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. Let’s take a look…
PA Regulations Training March 2010
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: 20610 x 100% of FS value
Right hip: 20610 x 50% of FS value
Right knee: 20610 x 50% of FS value
3 Injections
PA Regulations Training March 2010
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: 20610 x 100% of FS value TOS 2, Units: 1
PA Regulations Training March 2010
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:
62278 lumbar epidural: 100% FS
64440 injection paravertebral nerve:
50% FS
20550 trigger point injection:50% FS
PA Regulations Training March 2010
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 patient’s 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.
PA Regulations Training March 2010
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.