Anesthesia Medical billing Guidelines and procedure codes. Coding tips

The Part B Contractor must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time if:
• The physician personally performed the entire anesthesia service alone;

• The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in §100, and the service is furnished on or after January 1, 1996;

• The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physician criteria in §100.1.4 and the service is furnished on or after January 1, 2010;

• The physician is continuously involved in a single case involving a student nurse anesthetist;

• The physician is continuously involved in one anesthesia case involving a CRNA (or AA) and the service was furnished prior to January 1, 1998. If the physician is involved with a single case with a CRNA (or AA) and the service was furnished on or after January 1, 1998, carriers may pay the physician service and the CRNA (or AA) service in accordance with the medical direction payment policy; or

• The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary. Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the “AA” modifier and the CRNA reports the “QZ” modifier for a nonmedically directed case.

Claim Filing
Effective for dates of service on or after January 1, 2014, Blue Cross requires claims for anesthesiologists, CRNAs and AAs to be billed under the name and National Provider Identifier (NPI) of the provider who actually rendered the service. Blue Cross does not recognize “incident to” billing for anesthesia services. All providers should render services based on the scope of their particular license and requirements of the State of Alabama. Practitioners (anesthesiologists, CRNAs and AAs) must each file for the professional anesthesia services they performed electronically on the electronic 837 Professional 5010. For CRNA services performed on or after January 1, 2014, services will no longer be reimbursed through the hospital Blue Cross Cost Study. Both CRNA costs and charges should be excluded from the costs and charges reported in the hospital Blue Cross Cost Study.

Coding

Qualified anesthesia providers may bill directly for services using CPT anesthesiology codes 00100 – 01999. While some surgical CPT codes are appropriate to use when billing anesthesia services (e.g., CPT code 36620) the majority of anesthesia services should be billed using codes in the range of 00100 – 01999.

Base Units
The base unit is the value assigned to each CPT code and includes all usual services except the time actually spent in anesthesia care. Pre-operative and post-operative visits are usually included. When multiple anesthesia services are performed, only the anesthesia services with the highest base unit value should be filed with total time for all services reported on the highest base unit value. The base units value should never be entered in the “units” field when filing claims. Effective for dates of service on or after January 1, 2014, Blue Cross will utilize the Centers for Medicare & Medicaid Services (CMS) base unit values.

The Part B Contractor determines payment for the physician’s medical direction service furnished on or after January 1, 1998, on the basis of 50 percent of the allowance for the service performed by the physician alone. Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities.

• Performs a pre-anesthetic examination and evaluation;

• Prescribes the anesthesia plan;

• Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;

• Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;

• Monitors the course of anesthesia administration at frequent intervals;

• Remains physically present and available for immediate diagnosis and treatment of emergencies; and

• Provides indicated-post-anesthesia care.

Prior to January 1, 1999, the physician was required to participate in the most demanding procedures of the anesthesia plan, including induction and emergence.
For medical direction services furnished on or after January 1, 1999, the physician must participate only in the most demanding procedures of the anesthesia plan, including, if applicable, induction and emergence. Also for medical direction services furnished on or after January 1, 1999, the physician must document in the medical record that he or she performed the pre-anesthetic examination and evaluation. Physicians must also document that they provided indicated post-anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedures, including induction and emergence, where indicated.
For services furnished on or after January 1, 1994, the physician can medically direct two, three, or four concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs, interns, residents or combinations of these individuals. The medical direction rules apply to cases involving student nurse anesthetists if the physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern or resident.

For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents.

If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.

A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in furnishing additional services to other patients. However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous, monitoring of an obstetrical patient does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.

However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. Carriers may not make payment under the fee schedule.

Physicians bill for the anesthesia services associated with multiple bilateral surgeries by reporting the anesthesia procedure with the highest base unit value with the multiple
procedure modifier “-51.” They report the total time for all procedures in the line item with the highest base unit value.

If the same anesthesia CPT code applies to two or more of the surgical procedures, billers enter the anesthesia code with the “-51” modifier and the number of surgeries to which the modified CPT code applies.

Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures.

Payment at Medically Supervised Rate

The Part B Contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit may be recognized if the physician can document he or she was present at induction.

Payment for Medical and Surgical Services Furnished in Addition to Anesthesia Procedure

Payment may be made under the fee schedule for specific medical and surgical services furnished by the anesthesiologist as long as these services are reasonable and medically necessary or provided that other rebundling provisions (see §30 and Chapter 23) do not preclude separate payment. These services may be furnished in conjunction with the anesthesia procedure to the patient or may be furnished as single services, e.g., during the day of or the day before the anesthesia service. These services include the insertion of a Swan Ganz catheter, the insertion of central venous pressure lines, emergency intubation, and critical care visits.

Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished on or after January 1, 2000, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

Actual anesthesia time in minutes is reported on the claim. For anesthesia services furnished on or after January 1, 1994, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place. The A/B MAC does not recognize time units for CPT codes 01995 or 01996.

For purposes of this section, anesthesia practitioner means a physician who performs the anesthesia service alone, a CRNA who is not medically directed, or a CRNA or AA, who is medically directed. The physician who medically directs the CRNA or AA would ordinarily report the same time as the CRNA or AA reports for the CRNA service.

H
. Base Unit Reduction for Concurrent Medically Directed Procedures

If the physician medically directs concurrent medically directed procedures prior to January 1, 1994, reduce the number of base units for each concurrent procedure as follows.

• For two concurrent procedures, the base unit on each procedure is reduced 10 percent.

• For three concurrent procedures, the base unit on each procedure is reduced 25 percent.

• For four concurrent procedures, the base on each concurrent procedure is reduced 40 percent.

• If the physician medically directs concurrent procedures prior to January 1, 1994, and any of the concurrent procedures are cataract or iridectomy anesthesia, reduce the base units for each cataract or iridectomy procedure by 10 percent.

According to CPT guidelines, anesthesia time begins when the anesthetists begins to prepare the patient in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance and the patient may be safely placed under post-anesthetic supervision. Anesthesia time should be reported in minutes. Effective for dates of service on or after January 1, 2014, for all Anesthesiologists, CRNAs and AAs, one unit of time will be allowed for each 15 minute increment of anesthesia or a fraction thereof.

Reimbursement for time based anesthesia is based on the following formulas:

Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier)
(Base Factor + Total Time Units) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance

Anesthesia Performed under Medical Direction (QK, QX and QY modifiers)
[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Anesthesia “base unit” is the number of units assigned for the anesthetic management of surgical procedures using nationally recognized anesthesia base value standards. Base units are automatically calculated and should not be reported on the claim form. Blue Cross will utilize the CMS base unit values.

Anesthesia time should be submitted on the claim as total minutes. For example, one hour and nine minutes of anesthesia time is billed as 69 minutes. Blue Cross then converts minutes into 15-minute increments. This calculation would be four 15 minute time units and 9/15 of one unit. Total time units for this example are 4.6.

Blue Cross recognizes that the patient must be prepared immediately prior to induction and that some time may be spent immediately after the conclusion of the surgical procedure. Generally, no more than one unit should be necessary to prepare the patient for post-operative transfer to the recovery room. It is inappropriate to bill for anesthesia time while the patient is waiting in a holding area. If it is necessary for a more extensive service to be provided, documentation must be provided in the patient’s medical record to substantiate medical necessity. It is inappropriate to bill time units for services such as administration of blood products or antibiotics in the holding area, when such services could be provided in another area of the hospital or facility.

Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and the remaining a Medicare patient, this represents three concurrent cases. The following example illustrates this concept and guides physicians in determining how many procedures they are directing.

EXAMPLE

Procedures A through E are medically directed procedures involving CRNAs and furnished between January 1, 1992 and December 31, 1997 (1998 concurrent instructions can be found in subsection C.) The starting and ending times for each procedure represent the periods during which anesthesia time is counted. Assume that none of the procedures were cataract or iridectomy anesthesia.

Procedure A begins at 8:00 a.m. and lasts until 8:20 a.m.
Procedure B begins at 8:10 a.m. and lasts until 8:45 a.m.
Procedure C begins at 8:30 a.m. and lasts until 9:15 a.m.
Procedure D begins at 9:00 a.m. and lasts until 12:00 noon.
Procedure E begins at 9:10 a.m. and lasts until 9:55 a.m.

Procedure Number of Concurrent Medically Directed Procedures Base Unit Reduction Percentage

A2 10%
B210%
C325%
D325%
E325%

From 8:00 a.m. to 8:20 a.m., the length of procedure A, the anesthesiologist medically directed two concurrent procedures, A and B.

From 8:10 a.m. to 8:45 a.m., the length of procedure B, the anesthesiologist medically directed two concurrent procedures. From 8:10 to 8:20 a.m., the anesthesiologist medically directed procedures A and B. From 8:20 to 8:30 a.m., the anesthesiologist medically directed only procedure B. From 8:30 to 8:45 a.m., the anesthesiologist medically directed procedures B and C. Thus, during procedure B, the anesthesiologist medically directed, at most, two concurrent procedures.
From 8:30 a.m. to 9:15 a.m., the length of procedure C, the anesthesiologist medically directed three concurrent procedures. From 8:30 to 8:45 a.m., the anesthesiologist

medically directed procedures B and C. From 8:45 to 9:00 a.m., the anesthesiologist medically directed procedure C. From 9:00 to 9:10 a.m., the anesthesiologist medically directed procedures C and D. From 9:10 to 9:15 a.m., the anesthesiologist medically directed procedures C, D and E. Thus, during procedure C, the anesthesiologist medically directed, at most, three concurrent procedures.

The same analysis shows that during procedure D or E, the anesthesiologist medically directed, at most, three concurrent procedures.

59 Distinct Procedural Service — Services with modifier 59 may be subject to review of medical records. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Modifier 25 should be used only if a more descriptive modifier is not available, and the use of modifier 59 best explains the circumstances. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

73 Discontinued Outpatient Hospital/ASC procedure prior to the administration of anesthesia— Due to extenuating circumstances or those that threaten the wellbeing of
the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia [local, regional block(s) or general]. Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure code and the addition of modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

74 Discontinued Outpatient Hospital/ASC procedure after the administration of anesthesia— Due to extenuating circumstances or those that threaten the wellbeing of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia [local, regional block(s), general] or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure code and the addition of modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia. Prior to 2006, Medicare did not recognize separate payment if the same physician provided the medical or surgical procedure and the anesthesia needed for the procedure.

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care. In 2006, the CPT added new codes 99143 to 99150 for moderate or conscious sedation. The moderate (conscious) sedation codes are carrier priced under the Medicare physician fee schedule.

The CPT codes 99143 to 99145 describe moderate sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status. The physician can bill the conscious sedation codes 99143 to 99145 as long as the procedure with it is billed is not listed in Appendix G of CPT. CPT codes 99148 to 99150 describe moderate sedation provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports.

The CPT includes Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation. This appendix lists those procedures for which moderate (conscious) sedation is an inherent part of the procedure itself. CPT coding guidelines instruct practices not to report CPT codes 99143 to 99145 in conjunction with codes listed in Appendix G. The National Correct Coding Initiative has established edits that bundle CPT codes 99143 and 99144 into the procedures listed in Appendix G.

In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting for the procedures listed in Appendix G, the second physician can bill 99148 to 99150. The term, facility, includes those places of service listed in Chapter 23
Addendum -- field 29. However, when these services are performed by the second physician in the nonfacility setting, CPT codes 99148 to 99150 are not to be reported.

If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991. The service must meet the criteria for monitored anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the carrier. There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

Anesthesia for Burns

CPT code 01952 is the primary code for billing Anesthesia for Second and Third Degree Burn Excision or Debridement With or Without Skin Grafting. The add-on CPT code 01953 is not considered an anesthesia management service and should not be reported with time. CPT code 01953 may be reported with units of service up to a maximum of 10. This procedure will be paid from the fee schedule rather than the anesthesia calculation with time and base units. CPT code 01952 and addon code 01953 must be filed with the appropriate modifier in the first position.

Nerve Blocks When introduction or injection of anesthetic agent is administered the anesthetic agent is included in the payment for the actual procedure and not separately billable.

Epidural Catheters Intractable Pain

For control of intractable pain that is resistant to conventional forms of therapy (i.e., physical therapy, TENS units, etc.) payment may be allowed for the placement of a catheter. In addition, CPT code 01996 (daily management) may be billed on a daily basis as long as an identifiable service is being rendered by the anesthesiologist, CRNA or AA and deemed medically necessary and within the scope of their license. CPT code 01996 is not allowed on the same day as placement of an epidural catheter.

A. GENERAL BILLING INFORMATION

Electronic (EDI) HIPPA 5010 compliant 837P format claim submission - Submit total time in minutes in the appropriate field

Paper claim submission

- Submit claim using the most current CMS-1500 form.
- Submit total minutes in the unit field.
- Submit actual start and stop time (ex. 12:00 to 13:00 or 12:00 pm to 1:00 pm) on the claim form above the anesthesia CPT code field.

All claims for anesthesiologists and CRNAs must be billed under the name and National Provider Identifier (NPI) of the provider who actually rendered the service. “Incident to” billing for anesthesia services is not recognized by Neighborhood. All providers should render services based on the scope of their particular license.

Anesthesia Service Codes *not an all-inclusive list

CPT Code - 00100 to 00936, 00940 to 01999, 62273, 99100 to 99150
HCPCS Code - D9220, D9221 (D-codes only covered for oral surgery)

Anesthesia Modifiers *not an all-inclusive list.

Modifiers must be billed with anesthesia procedure codes to indicate whether the procedure was personally performed, medically directed or medically supervised.

Service will deny:

· When billed without appropriate modifier for provider’s specialty
· When modifier is not billed in the appropriate modifier position.
· When billed with invalid modifier combinations. (see incorrect modifier billing combination grid below)
· If not billed in accordance with standard coding/billing guidelines and Neighborhood’s policies

Incorrect Billing Modifiers

Modifier Do Not file on the same claim line with:
AA – Anesthesiologists AD, QY, QK, QX, or QZ
QY – Anesthesiologists AA, AD, QK, QX, or QZ
QK – Anesthesiologists AA, AD, QY, QX, or QZ
AD – Anesthesiologists AA, QY, QK, QX, or QZ
QX – CRNAs AA, AD, QY, QK, or QZ
QZ – CRNAs AA, AD, QY, QK, or QX

Anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and / or risk factors.

Codes and Definitions

99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)

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 (specify) (List separately in addition to code for primary anesthesia procedure)

This code is eligible for separate reimbursement at the allowed amount. Separately in addition to code for primary anesthesia proedure. Thi code are assigned a status indicator of "B" (bundled code) on the CMS Physician Fee schedule, and are not eligible for separate reimbursement uder Medicare guidelines. As per CMS, the value for the qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes. Payment for these services is always included in payment for other services not sprcified. There are no RVUs or payment amoount for these codes and separate payment is not made.

Coding Guidelines

CPT Assistant:
“Question: What are "qualifying circumstances for anesthesia," and when are they reported?

Answer: Codes 99100-99140 are add-on codes that include a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These circumstances would be reported as additional procedure numbers qualifying an anesthesia procedure or service. More than one code in the section may be selected, if applicable. Codes 99100-99140 are listed in the Anesthesia guidelines in the CPT codebook.” (AMA2)

Medicare Physician Fee Schedule:

Qualifying circumstances CPT codes 99100 – 99140 are assigned a status indicator of “B” (bundled code) on the CMS Physician Fee Schedule, and are not eligible for separate reimbursement under Medicare guidelines. Per CMS, the value for these qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes.

Reimbursement Guidelines

Commercial lines of business

Effective for claims processed on or after 2/25/2016, Moda Health does not separately reimburse for CPT codes 99100 – 99140. This is based on their status indicator of “B” (bundled code) on the CMS Physician Fee Schedule.

CPT codes 99100 – 99140 will deny to provider liability with denial codes:

EX: 2M0 Service/supply is considered bundled or incidental. Not eligible for separate payment. Always bundled into a related service.

CARC: 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

RARC: M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

99100+ (Anesthesia for patient of extreme age, under 1 year and over 70 {list separately in addition to code for primary procedure}) bundles with 00326 (Anesthesia for all procedures on the larynx and tracheas in children less that 1 year of age), 00834 (Anesthesia for hernia repair in the lower abdomen (not otherwise specified, under 1 year of age) and 00836 (Anesthesia for hernia repair in the lower abdomen not otherwise specified, infants less that 37 weeks gestational age at birth and less than 50 week gestation age at time of surgery).

CPT code for Anesthesia for extensiveee spine and spinal cord procedures is 00670. RVG comment : Code 00670 is appropriate only if the surgical procedure includes segmental or non-segmental instrumentation as defined in CPT or if the procedure includes multiplle verteebral segments (minimum three vertebral bodies with the two associated interspaces.)

00600-00670 Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670]

Spinal Anesthesia: 1) Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord. 2) Loss of sensation due to a spinal lesion.

Anesthesia for Spinal Procedures

Code Code Description Base Unit

00600 Anesthesia for procedures on cervical spine and cord; nototherwise specified 10

00604 Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position 13

00620 Anesthesia for procedures on thoracic spine and cord; nototherwise specified 10

00625 Anesthesia for procedures on thoracic spine and cord; viaan anterior transthoracic approach; notutilizing 1 lungventilation 13

00626 Anesthesia for procedureson thoracic spine and cord; via an anterior transthoracic approach; utilizing 1lung ventilation 15

00630 Anesthesia for procedureson lumbar region; not otherwise specified 8

00670 Anesthesia for extensive spine and spinalcord procedures (eg, spinal instrumentation orvascular procedures 13

STATUS J
Status J codes are anesthesia services. Reimbursement for anesthesia services is based on the anesthesia fee schedule (not the Medicare Physician Fee Schedule), and there are no RVUs or payments contained in the MPFSDB for these services.

All the Spinal anesthesia CPT codes are comes under Status J codes.

Anesthesia claims are paid based on the following:

Time units + Base unit x Anesthesia Conversion factor. Neighborhood uses the Centers for Medicare and Medicaid Services (CMS) base unit values.

· Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier) (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance

· Anesthesia Performed under Medical Direction (QK, QX and QY modifiers) [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Anesthesia start time is defined as the time the anesthesiologist begins the preparation of the patient. Anesthesia end time is defined as the time when the patient is placed under post-operative care. Time anesthesiologist is not in personal attendance is non-billable.

Do not submit base unit values in the total minutes or units field on a claim. Base units are automatically calculated and paid in Neighborhood reimbursement

Calculating Time Units for Anesthesia Services and Rounding

Submit 1 unit for every 15-minute interval, rounding up to the next unit for 8 to 14
minutes, rounding down for 1 to 7 minutes.

Number of Minutes Service is Provided Number of Units to Bill

7 minutes or Less Do not Bill
8 minutes to < 23 minutes 1 unit
23 minutes to < 38 minutes 2 units
38 minutes to < 53 minutes 3 units
53 minutes to < 68 minutes 4 units
68 minutes to < 83 minutes 5 units
83 minutes to < 98 minutes 6 units
98 minutes to < 113 minutes 7 units
113 minutes to < 128 minutes 8 units

Anesthesia for all procedures on the integumentary system,muscles and nerves of head, neck and posterior trunt, not otherwise specified.

Anesthesia for lesion removal is usually performed by the surgeon, If because of the size of the lesion, age or mental status of the patient, or if other conditions are present, the medical necessity of an anethesiologist may be supported. Include any appropriate Icd code necessary or attach report. The appropriate modifier indicating the type of procider as well as the type of service being rendered should be appended tot he procedure code. Modifiers indicating the physical status of the patient should also be appened when required by the third party payer. Medicare does not recognize physical status modifiers.

Monitored Anesthesia Care (MAC)

CPT code 00300 ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS

MAC provided by qualified anesthesia personnel may be reimbursed for these procedures only when one or more of the following conditions are met:

1. It qualifies for use of HCPCS modifier QS:

MAC is appropriate for:

Combative patients
Patients with low pain thresholds or who experience severe pain
Situations where the surgeon anticipates the possible intra-operative expansion of a procedure
Any condition in a Medicare eligible pediatric patient less than 12 years of age
The patient has a physical status grade of P3 or higher noted in the medical record
This modifier may only be submitted with anesthesia procedure codes (i.e., CPT codes 00100-01999)
Submit HCPCS modifier QS to indicate that the anesthesia service performed as monitored anesthesia care
This modifier is informational only. You must report actual anesthesia time on the claim
Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier QS second

2. It qualifies for use of HCPCS modifier G8 because the procedure being performed is for access to the central venous circulation (CPT code 00532); or is deep, complex, complicated or markedly invasive, and performed on an area of the body that is very sensitive. These areas include the face (CPT codes 00100 and 00160), neck (CPT code 00300), breast (CPT code 00400), or male genitalia (CPT code 00920).

Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier G8 second

3. It qualifies for use of HCPCS modifier G9 because the patient has or had a severe cardiopulmonary condition and MAC is appropriate to prevent intra-operative catastrophe.

Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier G9 second

Q. Why has Blue Cross made a decision to contract with CRNAs and AAs?
Healthcare Reform Provider Non-discrimination PPACA § 1201; PHSA § 2706(a) NON-DISCRIMINATION IN HEALTH CARE requires that group health plans and health insurers shall not discriminate against health care providers acting within the scope of their license or certification under the laws of the state of Alabama. In order to be in compliance, Blue Cross reviewed all provider types to ensure that providers covered under this provision could file claims. Changes were necessary for CRNAs and AAs.

Q. If a CRNA is already enrolled with Blue Cross, does he or she need to reapply for the CRNA Network?
Yes, having a provider number and being “credentialed” for the networks are not the same thing. All providers applying for network participation with any network must go through the same process.

Q. What is required to apply for the CRNA Network?
Providers must complete the Physician Extender Application, all supporting forms, and provide the requested documentation. Missing forms or required documentation will slow down the credentialing process.

Q. Will the Federal Employee Program (FEP) CRNA Network remain in place?
Effective January 1, 2014, the new CRNA Network will replace any existing networks, including the FEP CRNA Network.

Q. Will groups exclude CRNAs as eligible providers?
No, groups will no longer exclude CRNAs as eligible providers

Q. How were the services provided by CRNAs/AAs reimbursed previously?
Blue Cross traditionally reimbursed physicians for the services provided by CRNAs/AAs under an “incident to” arrangement. Hospital-employed CRNAs/AAs were reimbursed directly by the hospital. Anesthesiologists employing a CRNA/AA were reimbursed through the physician claim and received an extra unit for the cost of employment and were paid on 15-minute time units. Anesthesiologists that used hospital-employed CRNAs did not receive an extra unit and were paid on 30-minute time units.

Q. Will the anesthesiologist employing CRNAs/AAs still receive an extra unit?
Effective for services rendered on or after January 1, 2014, employing CRNAs/AAs will not result in any extra units added to the anesthesia calculations. Time units will all be calculated based on 15-minute units.

Q. Will the anesthesiologist using hospital-employed CRNAs/AAs have 30-minute time units?
No, all anesthesia time calculations will be based on 15-minute time units.

Not reimbursed separately but should be billed when appropriate

99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70
99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia
99135 – Anesthesia Complicated By Utilization of Controlled Hypotension
99140 – Anesthesia Complicated By Emergency Conditions

Non-reimbursable Services

Services billed by anesthesia assistants
Services provided by students

CRNA services performed by salaried facility employees

 Post-operative pain management on the same day as surgical procedure
 Anesthesia by the operating surgeon
 Anesthesia stand by
 Anesthesia for procedures not designated as requiring anesthesia
 Anesthesia for non-covered surgical procedures

Physical Status Modifiers

No additional reimbursement will be made when these modifiers are billed but should be submitted when appropriate

P1 Normal healthy patient
P2 Patient with mild systemic disease
P3 Patient with severe systemic disease
P4 Patient with severe systemic disease that is a constant threat to life
P5 Moribund patient who is not expected to survive without the operation
P6 Declared brain-dead patient whose organs are being removed for donor
purposes

Q. What defines medical direction?

For each anesthesia procedure, the anesthesiologist must perform all of the following seven services and they must be recorded in the anesthesia record:
1. Perform a pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthsia plan including, if
applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed
by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain physically present and available for immediate diagnosis and treatment of
emergencies; and
7. Provide all the indicated post-anesthesia care.

Q. What will happen if the modifiers are not on the claims?
These edits will be specific to the provider’s specialty, and claims that do not contain the appropriate modifiers or have inappropriate modifier combinations will be returned to the provider for correction.

Q. What are the specialty and modifier requirements?

• Anesthesiologist:
AA - Anesthesia services performed personally by the anesthesiologist
AD - Medical supervision of five or more concurrent anesthesia procedures by an anesthesiologist
QK - Medical direction (by anesthesiologist) of two, three or four concurrent procedures
QY - Medical direction of one CRNA/AA by an anesthesiologist
• CRNA/AA:
QX - CRNA/AA service with medical direction by an anesthesiologist
• CRNA:
QZ - CRNA service without medical direction by an anesthesiologist

C. Documentation For Anesthesia Record

General Documentation Requirements for all services:

· Anesthesia services performed, including exact time spent performing anesthesia services, must be documented in the anesthesia record to support billing.

· Rendering practitioner/qualified healthcare professional must note their credentials and legibly sign and date the record.
· Member identifying information must be present on all pages of the record.
· Documentation must be legible.

Medical Direction Documentation Requirements

For each anesthesia procedure, the anesthesiologist must document that he/she performed the following seven services and record each in the patient’s anesthesia record:

1. A pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain immediately physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provide the indicated post-anesthesia care.

Medical Supervision Documentation Requirements
When the anesthesiologist does not fulfill all of the “medical direction” requirements listed above, the anesthesia services are considered medical supervision services. Documentation must indicate if the anesthesiologist was present at induction.

Payment at Personally Performed Rate

BCBS claim filing limit for Anesthesia claims

Payment at the Medically Directed Rate

Billing and Payment for Multiple Anesthesia Procedures

Anesthesia Time and Calculation of Anesthesia Time Units

Anesthesia Time calculation for personally performed and Medical direction

Definition of Concurrent Medically Directed Anesthesia Procedures with time calculation example

When to use Modifier 59, 73, 74 IN Anesthesia billng?

Anesthesia and Medical/Surgical Service Provided by the Same Physician

CPT code 01952, 01996

Anesthesia billing Which form to use

Anesthesia incorrect modifier usage

CPT code 99100, 99116, 99135, 99140 - Billing tips

CPT Code for Spinal Anesthesia

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BILLING Guide CPT code 00300

Anesthesia and CRNA billing question?

Anesthesia add on code 99100, 99116, 99135 and 99140

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How to maintain document for Anesthesia billing