provided by coventry health care® ©2010 coventry health care. all rights reserved. proprietary...

Provided by Coventry Health Care®

©2010 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care..

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...


Services


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


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.


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.


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

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.


Modifiers


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



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.



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



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.


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.



*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.



QX

QY

QZ

Recap of Modifiers

CRNA without supervision

Anesthesiologist supervision of CRNA

Supervised CRNA


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


Pain Management Services

Pain management occurs in two distinct circumstances:

Let’s take a look…

Post-operative Pain Control Chronic Pain Control



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.


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.


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.


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.



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.


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.


However, the most common treatment is

injection.



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.



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.



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.



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…



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



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



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



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.


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.

provided by coventry health care® ©2010 coventry health care. all rights reserved. proprietary...

Documents