Basic things on anesthesia billing

September 8, 2016, 7:26 am

≫ Next: Anesthesia Billing Guidelines Reminder and Reference

≪ Previous: How to maintain document for Anesthesia billing

Anesthesia Billing

When a physician bills for anesthesia services, the correct procedure code and modifiers indicate one of the following below:

1. Services were personally provided by the physician to the individual patient - No modifier is needed; or

2. The physician provided medical direction for CRNA services and the number of concurrent services directed.

Anesthesiologists: The following modifiers must be used by the anesthesiologist when claiming medical direction of CRNA's:

AA - Anesthesia services performed personally by anesthesiologist

QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

Note: This is paid as a physician service. If both a CRNA and an anesthesiologist are involved in the same procedure, only the anesthesiologist is paid.

QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

Claims for these services must indicate actual time in one-minute increments in Field 24 G. All claims must be one-line claims. (For example, when Field 24 D, description of service, indicates "1" hour and 30 minutes, Field 24 G should be 90). The physician's personal services, up to and including induction, are considered the professional component. For induction only, the physician claims only one unit of anesthesia.

Anesthesia time begins when the anesthesiologist is personally in control of the patient in the operating room or equivalent area, and ends when the patient may be safely placed under post-operative supervision and the physician is no longer in attendance.

Certified Registered Nurse Anesthetists (CRNA's): Enter the anesthesia procedure code (00100-01999). The CRNA may bill directly, or through the physician employer or hospital (all must billed on Form CMS-1500). Exception: Rural hospitals that have been exempted by their Medicare intermediary for CRNA billing must follow the Medicare billing requirements.

The following modifiers must be used by CRNA's when claiming anesthesia services:

QX - CRNA service: with medical direction by a physician

QZ - CRNA service: without medical direction by a physician

Claims for these services must indicate actual time in one-minute increments in Field 24 G. For example, when Field 24 D indicates "1 hour and 30 minutes," Field 24 G should be 90.
Anesthesia time begins when the CRNA is personally in control of the patient in the operating room or equivalent area, and ends when the patient may be safely placed under post-operative supervision and the CRNA is no longer in attendance.

Claim payments will be calculated by adding the unit value for the procedure to the number of minutes for the procedure and multiplying by the appropriate conversion factor for each code with the appropriate modifier.

↧

Anesthesia Billing Guidelines Reminder and Reference

September 13, 2016, 7:28 am

≫ Next: CPT CODE 99143, 99144 AND 99145

≪ Previous: Basic things on anesthesia billing

The following is a reminder of the billing guidelines for anesthesia services for UnitedHealthcare Community Plan:

 Anesthesia Services - General or monitored anesthesia management services must be
submitted with a CPT anesthesia code 00100-01999, except 01953 and 01996. Refer to
the Anesthesia Management Codes in the Anesthesia Policy for all applicable codes.

 Time Reporting – Consistent with Centers for Medicaid & Medicare Services (CMS)
guidelines, time-based anesthesia services must be reported with anesthesia time in oneminute increments. For example, if the anesthesia time is one hour, then 60 minutes
should be submitted.

 Anesthesia Modifiers – All services reported for anesthesia management must be
submitted with the appropriate HCPCS modifiers. These modifiers identify monitored
anesthesia and whether a procedure was personally performed, medically directed or
medically supervised. Consistent with CMS guidelines, the allowance will be adjusted by
the modifier percentage indicated in the table in the Anesthesia Policy.

Claims not submitted per the Anesthesia Policy are subject to denial.

↧

CPT CODE 99143, 99144 AND 99145

September 15, 2016, 2:51 am

≫ Next: CPT CODE 64450, 64415

≪ Previous: Anesthesia Billing Guidelines Reminder and Reference

CPT CODE and Description

99143 - Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional 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; younger than 5 years of age, first 30 minutes intra-service time

99144 - Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional 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; age 5 years or older, first 30 minutes intra-service time

99145 - Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional 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; each additional 15 minutes intra-service time

Policy: The anesthesia payment policy in Pub. 100-04, chapter 12, section 50 is being revised so that it is consistent with the pricing of the conscious sedation codes under the Medicare physician fee schedule and CPT coding guidelines. The new policy is as follows:

If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines. If the physician performing the procedure also provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service. The carrier shall follow the NCCI edits imposed for codes 99143 and 99144 if billed with any procedure in Appendix G of the CPT.

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.

Three of these codes (99143, 99144, and 99145) describe the scenario in which the same physician performing the diagnostic or therapeutic procedure provides the moderate sedation, and an independent trained observer’s presence is required to assist in the monitoring of the patient’s level of consciousness and physiological status. The other three codes (99148, 99149, and 99150) describe the scenario in which the moderate sedation is provided by a physician other than the one performing the diagnostic or therapeutic procedure.

CR 5618 presents some specific points that you should be aware of:

• CPT coding guidelines for conscious sedation codes instruct practices not to report Codes 99143 to 99145 in conjunction with the codes listed in CPT Appendix G. Your carrier or A/B MAC will follow the National Correct Coding Initiative, which added edits in April 2006 that bundled CPT codes 99143 and 99144 into the procedures listed in Appendix G (There are no edits for code 99145; it is an add-on-code and it is not paid if the primary code is not paid.).

BCBS Guidelines

Coverage of IV moderate sedation is appropriate for patients undergoing surgical or endoscopic procedures when general, local, or regional anesthesia is not the more appropriate choice. These decisions are based on the patient's medical condition, age, and the type of procedure.

Reimbursement for moderate sedation is built into the compensation valuation for many procedures. The oversight of the physician is inherent in the procedure allowance and the staff time is inherent in the facility allowance. Therefore, moderate sedation by the physician performing the procedure is not separately reimbursed (CPT codes 99143, 99144, 99145).

Coding:

99144 (NOT SEPARATELY REIMBURSED)

• The sedation service must be medically necessary for the management of the patient. Preliminary data analysis of claims submitted for these services indicates that CPT codes 99144–99145 are being billed with routine injection services and other minor procedures for which moderate sedation may not be “reasonable.” Title XVIII of the Social Security Act, Section 1862(a)(1)(A), states “... No payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

• Report only the time of face-to-face physician contact, starting with the time when the physician starts the anesthesia to the time the physician breaks face-to-face contact. The reported time stops when the physician breaks face-to-face contact, even if the trained observer stays for a longer period of time to monitor recovery. The additional time the trained observer stays to monitor recovery after the physician leaves the patient’s bedside is not a service separately billable to Medicare. The Medicare “incident to” provisions do not apply to this service since the service is defined in terms of face-to-face physician time.

• These codes may not be used to report a level of anesthesia lower in intensity than moderate or conscious sedation such as local or topical anesthesia or minimal sedation.

• For this service, Medicare defines a “physician” as an MD, DO or other physicians and non-physician practitioners licensed by the state to perform conscious sedation in addition to the diagnostic or therapeutic service for which sedation is required.

moderate/Conscious Sedation - Time Examples

Below are some examples of moderate/conscious sedation time. ** 1 - 15 minutes of intraservice time = No CPT code assigned as the mid-point has not been reached;

service included in the E/M level.

** 16 - 37 minutes of intraservice time = Code for 1st 30 minutes

** 38 - 52 minutes = Code for 1st 30 minutes + 1 unit of the each additional 15 minutes code (i.e., 99144, 99145)

** 53 - 67 minutes = Code for 1st 30 minutes + 2 units of the each additional 15 minutes code (i.e., 99144, 99145, 99145)

** 1 hr, 20 minutes - Codes for 1st 30 minutes + 3 units of the each additional 15 minutes code (i.e., 99144, 99145, 99145, 99145)

In closing, Moderate Sedation Services are frequently provided in the Emergency Department setting. Emergency Department Physicians should familiarize themselves with the time measurement changes to the Moderate Sedation codes as these changes directly affect coding and billing. It is required that the physician document the length of intra-service time providing Moderate Sedation Services. Without a time statement these services are not billable because the coder cannot assume that the minimum time threshold of 16 minutes has been met.

↧

CPT CODE 64450, 64415

September 21, 2016, 2:10 am

≫ Next: CPT CODE 64483, 64479, 64484 - Anesthetic agent

≪ Previous: CPT CODE 99143, 99144 AND 99145

cpt code and description

64450 - Injection, anesthetic agent; other peripheral nerve or branch - average fee amount - $80 - $100

64415 - Injection, anesthetic agent; brachial plexus, single Average fee amount - $110 - $130

Injections for Post-Operative Pain Control

When a patient is to receive an Injection or has a Catheter placed during an Arthroscopic Shoulder surgical procedure for control of post-operative pain, there are certain requirements which must be met in order to bill the injection/Catheterization procedure separately.

o Do not bill to Medicare.

o The Injection/Catheterization procedure must be performed by a different physician (usually the anesthesiologist) from the surgeon who performs the ortho.

scope surgery.

o There must be a separate Procedure Report for the Post-Op Injection/ Catheterization procedure (it cannot be part of the surgeon’s OP Report or part of the Anesthesia Record).

o The Block must not be the only anesthesia for the case.

o If there is a separate report for the Injection/Catheterization procedure and the Injection/Catheterization procedure was performed by a different physician, you may bill for the Injection/Catheterization procedure. Use a different claim form from the Shoulder surgery procedure and bill the Injection/Catheterization procedure claim in the name of the anesthesiologist (or other physician) who performed the Injection/Catheterization procedure.

o Codes for billing Injection/Catheterization Shoulder post-operative pain procedures:

1. 64415 – Brachial Plexus Block (also use this code for an Interscalene Block) for a Single Injection OR

2. 64416 – Brachial Plexus Infusion by Catheter using a Pain Pump Medicare has issued specific guidance that in most cases they consider Injections performed routinely for Post-Operative Pain Control to be bundled into the orthopedic surgeon’s global services (even when the Injection is performed by a different physician), so we would recommend not billing them to Medicare.

If Injections are given for Post-Op Pain Control after Knee Surgery, the 64447 code for a Femoral Nerve Block Injection or code 64448 for a Femoral Block by Catheter using a Pain Pump would be used. Use code 64450 for Blocks for Ankle and Foot procedures.

For example, when an avulsion of a nail plate (CPT code 11730) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 11730 when the same physician performs both procedures

For example, when a small joint or bursa arthrocentesis, aspiration and/or injection (CPT code 20600) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 20600 when the same physician performs both procedures.

We require supporting clinical documentation in the use of Modifier 59 for a group of select National Correct Coding Initiatives (NCCI) edits. The documentation should substantiate the use of Modifier 59 in requesting separate reimbursement. This documentation should be supplied with the initial claim. We are adding 49 code pairs to the existing list. The code pairs that are being added are:

Denied Code Paid Code

64415 00450 64416 01630 64445 01480 64448 01480
64415 01400 64416 01638 64447 01320 64450 01400
64415 01480 64416 01710 64447 01392 64450 01402
64415 01610 64416 01740 64447 01400 64450 01464
64415 01620 64416 01810 64447 01402 64450 01470
64415 01630 64416 01830 64447 01464 64450 01472
64415 01638 64445 01320 64447 01470 64450 01480
64415 01710 64445 01392 64447 01472 64450 01630
64415 01740 64445 01400 64447 01480 64450 01810
64415 01810 64445 01402 64448 01320 64450 01830
64415 01830 64445 01464 64448 01392
64416 00450 64445 01470 64448 01400
64416 01610 64445 01472 64448 01402

↧

CPT CODE 64483, 64479, 64484 - Anesthetic agent

September 22, 2016, 10:51 pm

≫ Next: CPT 64635, 64636, 64633 - definition covered ICD

≪ Previous: CPT CODE 64450, 64415

CPT code and description

64479 - Injection, anesthetic agent and/or steroid, transforaminal epidural; Cervical or Thoracic, single level

64480 - Cervical or Thoracic, each additional level

64483 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level - average fee amount - $220 - $230

64484 – Lumbar or Sacral, each additional level

Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

Explanation of Revision: Annual 2011 HCPCS Update. Revised descriptors for CPT codes 64479, 64480, 64483 and 64484 in LCD. The effective date of this revision is based on date of service.

Coverage Indications, Limitations, and/or Medical Necessity

Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

1. Management of pain caused by intervertebral disc disease with or without myelopathy.

2. Management of pain caused by spinal stenosis.

3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

4. Management of intractable pain due to complex regional pain syndrome.

5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

9. Management of pain caused by radiculitis (inflammation of the nerve roots).

Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.

CPT/HCPCS Codes

For Single Injection Group 1 Codes
62310Inject spine cerv/thoracic
62311Inject spine lumbar/sacral

For Transforaminal Epidural Injections Group 2 Codes

64479Inj foramen epidural c/t
64480Inj foramen epidural add-on
64483Inj foramen epidural l/s
64484Inj foramen epidural add-on

Introduction/Injection of Anesthetic Agent (Nerve Bock), Diagnostic or Therapeutic

Fluoroscopic and computed tomographic (CT) guidance will be bundled into the 2011 editorially revised transforaminal epidural anesthetic and/or steroid injection codes 64479, 64480, 64483, 64484, as either fluoroscopic or CT guidance is required to perform these injections.

Note that ultrasound guidance is not included in the descriptor for codes 64479-64484; therefore, if ultrasound-guidance is used in place of fluoroscopic or CT guidance, one of the newly created Category III bundled ultrasound-guided transforaminal epidural injection procedure codes, 0228T- 0231T, should be reported as of January 1, 2011. Similar to the fluoroscopy and CT-guided paravertebral facet joint injection codes created in 2010, these codes are reported per level. If multiple injections are performed at a single level on the same side, the code should only be reported once.

Transforaminal Epidural Injection of Anesthetic Agent and/or Steroid (includes fluoroscopy or CT imaging guidance)*

Fluoroscopic or CT Guidance Ultrasound Guidance

Lumbar or Sacral 64483 0230T

Bundling Issues with ESI Procedures

The 64479 code is Unbundled in the CCI Edits from code 62310 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Code 64483 is Unbundled from code 62311 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Therefore, for Medicare and other payors who observe the CCI edits, these codes are not billable together when they are performed at the SAME spinal area. If the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L4-5, the procedures are Unbundled and not both billable – only code 62311 would be billable in that case. However, if the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L3-4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the 2nd code following the 62311 ESI code on the claim form.

↧

CPT 64635, 64636, 64633 - definition covered ICD

September 25, 2016, 11:04 pm

≫ Next: Billing Guide - Two anesthesiologist performed

≪ Previous: CPT CODE 64483, 64479, 64484 - Anesthetic agent

CPT NEW DESCRIPTION

64635 New code Destruction by neurolytic agent paravertebral facet joint nerve(s) (fluoroscopy or CT; Lumbar or sacral, single facet joint

(For bilateral procedure, report 64635 with modifier 50)

64636 New code Lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Paravertebral Facet Joint Denervation

1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.

Revision History Number/Explanation

01/01/2012 CPT 2012 code update deleted codes 64622, 64623, 64626 and 64627, added new codes 64633, 64634, 64635, and 64636 removed codes 77003, 77012 and references to them. 08/01/2011 correction to Paravertebral Facet Joint Denervation number 3. Fluoroscopic guidance and localization for needle placement, is not included in codes 64622-64627 effective 03/18/2010.

Coverage Indications, Limitations, and/or Medical Necessity

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. For the purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right.

Facet joint pain is generally suspected in patients with cervical, thoracic and or lumbar pain that may or may not have a radicular component, when focal tenderness is present over the facet joint, and increased symptoms due to rotation or extension of the spine.

Destruction of a paravertebral facet joint nerve(s) requires the use of fluoroscopic guidance to confirm the proper positioning of the needle or electrode at the level of the involved paravertebral facet joint(s). Destruction of the paravertebral facet joint nerve (s) (median branch) can then be achieved by means of thermal, electrical or radiofrequency (rhizotomy) applications. Facet joint nerve destruction is considered a definitive form of treatment for facet joint pain. Therefore, it would not be expected to see multiple repeat facet joint destruction procedures performed once all of the involved facet joints at that spinal level on either side have been denervated. However, the nerves do have the ability to regenerate. If pain recurs in the same distribution and nature, the procedure may be provided at a maximum of two (2) sessions per year (per 12 months).

Indications

The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows:

• The paravertebral facet joint(s) have been identified as the source of the patient’s pain by undergoing a diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and

• The patient failed conservative treatment. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic and

• The paravertebral facet joint(s) destruction is performed by appropriately trained providers.

The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services are "ordered and/or furnished by qualified personnel."

A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

Limitations

The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary when:

• Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint (median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or

• The medical records do not support that the patient experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection; or

• The medical records do not demonstrate that destruction was performed at the median branch of the spinal nerve innervating the facet joint.

Group 1 Codes
64633	Destroy cerv/thor facet jnt
64634	Destroy c/th facet jnt addl
64635	Destroy lumb/sac facet jnt
64636	Destroy l/s facet jnt addl

A patient undergoes a radiofrequency nerve destruction of two medial branch nerves L3 and L4 innervating the symptomatic lumbar facet joint. Reimbursement consideration is based upon the following code selection:

* 64635 — $516.47 (approximate 2012 ASC reimbursement) Coding tips:

* Image guidance and localization are required for the performance of paravertebral facet joint nerve destruction by neurolytic agent described by 64633-64636.

* Do not report 64633-64636 in conjunction with 77003 or 77012). Both CPT 77003 and/or 77012 are considered inclusive to the injection procedure in 2012. Note: If CT or fluoroscopic imaging is not used/documented, report unlisted CPT code 64999.

* If both facet joints at the same vertebral level are treated, then CPT 64633 or 64635 should be reported with modifier -50 appended pending carrier reporting requirements for bilateral procedures (-50 versus RT/LT versus units).

ICD-10 Codes that Support Medical Necessity

M47.011	Anterior spinal artery compression syndromes, occipito-atlanto-axial region
M47.012	Anterior spinal artery compression syndromes, cervical region
M47.013	Anterior spinal artery compression syndromes, cervicothoracic region
M47.014	Anterior spinal artery compression syndromes, thoracic region
M47.015	Anterior spinal artery compression syndromes, thoracolumbar region
M47.016	Anterior spinal artery compression syndromes, lumbar region
M47.019	Anterior spinal artery compression syndromes, site unspecified
M47.021	Vertebral artery compression syndromes, occipito-atlanto-axial region
M47.022	Vertebral artery compression syndromes, cervical region
M47.029	Vertebral artery compression syndromes, site unspecified
M47.11	Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12	Other spondylosis with myelopathy, cervical region
M47.13	Other spondylosis with myelopathy, cervicothoracic region
M47.14	Other spondylosis with myelopathy, thoracic region
M47.16	Other spondylosis with myelopathy, lumbar region
M47.21	Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22	Other spondylosis with radiculopathy, cervical region
M47.23	Other spondylosis with radiculopathy, cervicothoracic region
M47.24	Other spondylosis with radiculopathy, thoracic region
M47.25	Other spondylosis with radiculopathy, thoracolumbar region
M47.26	Other spondylosis with radiculopathy, lumbar region
M47.27	Other spondylosis with radiculopathy, lumbosacral region
M47.28	Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811	Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812	Spondylosis without myelopathy or radiculopathy, cervical region
M47.813	Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814	Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815	Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816	Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817	Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818	Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.891	Other spondylosis, occipito-atlanto-axial region
M47.892	Other spondylosis, cervical region
M47.893	Other spondylosis, cervicothoracic region
M47.894	Other spondylosis, thoracic region
M47.895	Other spondylosis, thoracolumbar region
M47.896	Other spondylosis, lumbar region
M47.897	Other spondylosis, lumbosacral region
M47.898	Other spondylosis, sacral and sacrococcygeal region
M54.2	Cervicalgia
M54.30	Sciatica, unspecified side
M54.31	Sciatica, right side
M54.32	Sciatica, left side
M54.5	Low back pain
M54.6	Pain in thoracic spine
M96.1	Postlaminectomy syndrome, not elsewhere classified

↧

Billing Guide - Two anesthesiologist performed

September 28, 2016, 7:51 am

≫ Next: General Billing Guidelines for Anesthesia

≪ Previous: CPT 64635, 64636, 64633 - definition covered ICD

One Procedure – Two Anesthesiologists or Two CRNAS

If one practitioner begins the anesthesia and has to leave the patient to start another procedure and a second practitioner finishes the procedure the one who is with the patient that spent the longest time with the patient can bill. That practitioner should report the combined total of minutes. Documentation must support the time spent by both practitioners.

Pain Management

Covered pain management services provided by anesthesia practitioners should be billed using the most appropriate CPT code. Modifiers AA, AD, QK, QX, QY or QZ should not be used. Neither should physical status modifiers P1 through P6 be used.

Types of Pain management includes the following:

• Post Operative pain management placement of epidural

• Post-operative pain management – daily hospital management of epidural (continuous) or subarachnoid (continuous) drug administration

• Should only be billed on post-operative days and not on the same day as the operative procedure

• Number of units should be billed not anesthesia time

Conscious Sedation

Conscious sedation is an altered level of consciousness that allows a patient to still respond to physical stimulation and verbal commands, and to maintain an unassisted airway. Conscious sedation is typically considered a part of the surgical procedure global package and not reimbursed separately.

In some cases however, a patient’s condition may warrant the use of conscious sedation with procedures where sedation is not normally used. This may include children, acutely agitated patients, or acutely ill patients who cannot have the procedure without sedation. The procedures included in this category that may require IV monitoring by an anesthesiologist include ndoscopies, arteriograms, CT scans, MRIs, cardiac catheterizations, and PTCA

↧

General Billing Guidelines for Anesthesia

October 13, 2016, 7:31 am

≫ Next: Anesthesiologist and CRNA required modifiers

≪ Previous: Billing Guide - Two anesthesiologist performed

Anesthesia billed by an anesthesia practitioner should be billed on the CMS 1500 or 837 P with the
appropriate 5-digit CPT code 00100 - 01995 or 01999 in effect for the date the services were rendered with the appropriate payment modifier.

There are four anesthesia categories as determined by CMS that affect payment of anesthesia services based on the provider rendering the services:

1. Personally Performed – The physician (MD) performs the service alone.

2. Medically Directed– The anesthesiologist is an active participant in the 1, 2, 3, or 4 concurrent cases. Meets the seven steps of medical direction.

o Performs a pre-anesthetic examination and evaluation;

o Prescribes the anesthesia plan;

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

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

o Monitors the course of anesthesia administration at frequent intervals;

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

o Provides indicated post-anesthesia care.

3. Medically Supervised– Not completing all steps required for medical direction above, performs a task that prohibits the anesthesiologist from medically directing or is involved in
more than four cases.

4. Teaching – Anesthesiologist is training physician residents in up to two concurrent cases,
or the training of a resident in one case while medically directing another case. In the second
scenario both cases would be billed separately with the right modifiers.

↧

Anesthesiologist and CRNA required modifiers

October 17, 2016, 8:41 am

≫ Next: BILLING Guide for CRNA Anesthesia services with example

≪ Previous: General Billing Guidelines for Anesthesia

Required Modifiers

Required Modifiers for Anesthesiologist Description Reimbursement

AA Anesthesia services personally performed by anesthesiologist
100 percent of allowable amount

AD Medical supervision by a physician, more than four concurrent anesthesia
procedures
Max 3 base units + time units) effective 10/1/2014 date of service

QK Medical direction of two, three or four concurrent anesthesia procedures
50 percent of allowable amount effective 10/1/2014 date of service

QY Medical direction of one C.R.N.A by anesthesiologist
50 percent of allowable amount effective 10/1/2014 date of service

Required Modifiers For CRNAs

QX Qualified non-physician anesthetist with medical direction by physician.
80 percent of the payment made for the QK or QY claim effective 10/1/2014 date of service

QZ CRNA service, without medical direction by anesthesiologist
80 percent of allowable amount effective 10/1/2014 date of service

↧

BILLING Guide for CRNA Anesthesia services with example

October 21, 2016, 8:48 am

≫ Next: Anesthesia for CAT Scans and MRI Procedures

≪ Previous: Anesthesiologist and CRNA required modifiers

Certified Registered Nurse Anesthetists (CRNA) Services

Neighborhood will require all CRNA(s) to become individually credentialed

Effective 10/1/2014 Neighborhood will begin reimbursing CRNA services at a percentage of anesthesia allowable. CRNA must be credentialed on the date of service in order to receive reimbursement for the service and all claims must be billed using the CRNA’s NPI as rendering provider
.
When a CRNA and a medically directing anesthesiologist provide services for a single anesthesia procedure, submit claims as follows:

· Submit separate claims for each practitioner using his/her NPI number
· Submit the same CPT procedure code and time on both claims
· Add to the procedure code on the supervising anesthesiologist’s claim:

Modifier Description
QY Medical direction of one CRNA by an anesthesiologist
· Add to the procedure code on the medically directed CRNA’s claim:

Modifier Description
QX CRNA service; with medical direction by a physician
-Payment would be 50 percent of the allowable amount of the service to the anesthesiologist and 80 percent of the anesthesiologist’s payment will be paid to the CRNA.

Example:

Procedure XXXX allowable is $100.00
Anesthesiologist payment is $50.00
CRNA payment is $50.00 x 80% = $40.00
When an anesthesiologist medically directs or supervises more than one CRNA submit claims as follows:

· Submit separate claims for each practitioner using his/her NPI number
· Submit the same CPT procedure code and time on both claims
· Add to the procedure code on the supervising anesthesiologist’s claim:

Modifier Description
QK Medical direction of 2,3, or 4 concurrent anesthesia procedures.
· Add to the procedure code on the medically directed CRNA’s claim:

Modifier Description
QX CRNA service; with medical direction by a physician
-Payment would be 50 percent of the allowable amount of the service to the anesthesiologist and 80 percent of the anesthesiologist’s payment will be paid to the CRNA.

Example:
Procedure XXXX allowable is $100.00
Anesthesiologist payment is $50.00
CRNA payment is $50.00 x 80% = $40.00

↧

Anesthesia for CAT Scans and MRI Procedures

October 25, 2016, 2:40 am

≫ Next: CPT code 69436, 69421, 69433, 69420 Tympanostomy general aneshtesia

≪ Previous: BILLING Guide for CRNA Anesthesia services with example

Payment can be made for anesthesia for computerized axial tomography (CAT) or magnetic resonance imaging (MRI) scans by Blue Cross if there is documentation supporting the medical necessity of the anesthesia such as:

• Convulsive disorders;
• Tremors of the head and body;
• Cerebral palsy, Parkinson’s Disease;
• Children too young to cooperate, and/or
• Uncooperative patient due to brain injury, mental derangement, mental deficiency, diseases of the brains, etc.

Patient Controlled Analgesia (PCA)

These services are covered separately when performed for the control of post-operative pain and billed by an anesthesiologist, CRNA or AA within the scope of their license. Otherwise, these services are included in the global surgery or other medical service. The usual route of administration via a PCA pump is through an intravenous line. When this service is provided through an intravenous line, an anesthesiologist will be allowed four additional units for providing management of the PCA pump. The global reimbursement covers any rate or dosage adjustments necessary during the post-operative period. Use CPT code 01999 to report this service

Local Anesthesia

Reimbursement for topical anesthesia, local anesthesia, local infiltration and/or metacarpal/digital block, is included in the basic allowance of the surgical procedure performed. No additional reimbursement is provided

↧

CPT code 69436, 69421, 69433, 69420 Tympanostomy general aneshtesia

October 25, 2016, 3:17 am

≫ Next: Billing Exclusions For Anesthesia

≪ Previous: Anesthesia for CAT Scans and MRI Procedures

procedure code and description

69436 - Tympanostomy (requiring insertion of ventilating tube), general anesthesia - average fee payment - $170 - $180

69420 Myringotomy including aspiration and/or eustachian tube inflation

69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia

69424 Ventilating tube removal requiring general anesthesia

69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia

69799 Unlisted procedure, middle ear S2225 Myringotomy, laser-assiste

Policy: A myringotomy (69420, 69421, or S2225) may be performed with or without the insertion of tympanostomy tubes. Insertion of tubes should be reported under code 69433 or 69436, as appropriate.

Removal of ventilation, myringotomy, or tympanostomy tubes (i.e., Shea or Collar button) may be paid when performed under general anesthesia (69424).

However, removal of such tubes is considered an integral part of a doctor's medical care when not performed under general anesthesia, and therefore, is not eligible as a distinct and separate service.

Mutually exclusive procedures

For example, CPT codes 69433 and 6 436 describe different types of tympanostomy requiring insertion of ventilating tube. CPT ode 69433 describes the procedure performed with local or topical ane thesia, and CPT code 69436 describes the procedure performed with general anesthesia. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.

Bilateral Procedures: Billing Clarification

When billing for bilateral procedures performed during the same session (unless otherwise directed in CPT), providers are to use the -50 modifier (Bilateral procedure) with the appropriate CPT code and place a “1” in the units field of the claim form. The site specific modifiers ‘LT’ (Left side) or ‘RT’ (Right side) may be used on appropriate CPT codes only when services are performed on either the right OR the left side.

Providers should not use the ‘LT’ and ‘RT’ modifier on the same procedure code instead of the -50 modifier. For example, during the same session it is not appropriate to use the ‘RT’ and ‘LT’ on CPT procedure code 69436 (Tympanostomy…) when performed bilaterally.

For questions related to this clarification, please contact Molina Medicaid Solutions Provider Services at (800)-473-2783 or (225)-924-5040.

Providers will no longer be able to bill for bilateral procedures on two lines with/without the modifi er -50, or on one line with a count of two.

Example: CPT 69436 billed with a 50 modifi er on a single date of service. CPT code billed a second time for the same date of service without the modifi er 50.

CODE DESCRIPTION RULE LINE

69436-50 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), ALLOW ALLOW GENERAL ANESTHESIA

69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), DISALLOW DISALLOW GENERAL ANESTHESIA

Explanation:

• Procedure code 69436 was performed bilaterally and submitt ed once with the modifi er -50.

• The second submission of procedure code 69436 with or without modifi er 50 is not recommended for separate reporting, because the procedure code was previously billed once on the same date of service with the modifier -50.

↧

Billing Exclusions For Anesthesia

October 30, 2016, 7:33 am

≫ Next: Billing Guide for Anesthesiology assitand and Anesthesia time

≪ Previous: CPT code 69436, 69421, 69433, 69420 Tympanostomy general aneshtesia

A surgeon or physician may not bill for anesthesia performed at the same time he/she is performing the surgery. This includes conscious sedation codes 99143, 99144, 99145, 99148, 99149 and 99150.

Conscious sedation and local anesthetic when performed with a procedure are considered to be a part of the global surgical package and not separately payable.

CRNAs

certified Registered Nurse Anesthetists (CRNA) are master’s prepared advanced practice nurses.

CRNAs provide anesthetics to patients in every practice setting, and for every type of surgery or procedure.

CRNAs provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other qualified healthcare professionals. Anesthesia administered by a nurse anesthetist is recognized as the practice of nursing. Anesthesia administered by an anesthesiologist is recognized as the practice of medicine. Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals give anesthesia the same way.

CRNAs may either be self-employed or work for a physician or facility based practice. There are currently 33 states that do require physician supervision of a CRNA. The determination as to whether the CRNA requires supervision is based on the scope of practice and licensing requirements for the state in which they practice. (See Table 1 for state and federal specific requirements). In states where a CRNA is allowed to practice independently there still may be CRNAs who work under the supervision of an anesthesiologist and should bill accordingly. It should be noted that CMS defers to state law regarding supervision of a CRNA though the federal requirement for Medicaid and Medicare states that a physician must supervise the CRNA

↧

Billing Guide for Anesthesiology assitand and Anesthesia time

November 5, 2016, 7:36 am

≫ Next: CPT code 62270, 62272, 62273

≪ Previous: Billing Exclusions For Anesthesia

Anesthesiology Assistants

Anesthesiology Assistants are eligible for the same level of reimbursements as a CRNA who is providing anesthesia under the direction of a physician. Unlike the CRNA who can perform alone in some states an AA must always perform their service under the direction of a physician. (See definition of Medical Direction in General Billing Guidelines for Anesthesia)

Anesthesia Units

Anesthesia should be billed in 15-minute increments. Each 15-minute increment equals 1 unit and the
number of units should be entered into field 24G. Calculation of time starts when the practitioner is
preparing the patient for anesthesia and ends when the practitioner is no longer providing anesthesia
services. It is a continuous service.

Billing Anesthesia For Multiple Surgeries

If multiple surgical procedures are being performed in the same operative session only one anesthesia
code may be submitted. Choose the code that represents the most complicated procedure (typically the service with highest CMS Relative Value Unit). An exception exists if the anesthesia performed requires the use of an add on anesthesia code in addition to the primary procedure. Example: Primary Procedure is 01967 with add-on codes 01968, 01969.

Basic

Qualified medical professionals administer anesthesia to relieve pain while at the same time monitoring and controlling the patients’ health and vital bodily functions. Anesthesiology may be performed in the hospital, and ambulatory surgical center, and a physician’s office. Anesthesiologists and anesthesiologist- led care teams provide anesthesia. These teams include non-physician providers
such as Certified Registered Nurse Anesthetists (CRNA), Anesthesiologist Assistant (AA), interns,
residents, or a combination of both who may be either medically directed or medically supervised by
an Anesthesiologist.

Anesthesia service includes:
1. Pre-anesthetic evaluation and management
2. Medical management of the patient during the procedure
3. Post-anesthetic evaluation and treatment
4. Anesthesiologist onsite direction of any non-physician who assists in the technical aspects of
anesthesia care to a patient

↧

CPT code 62270, 62272, 62273

November 9, 2016, 11:11 pm

≫ Next: CPT code 00640, 01935, 01936 and 01991

≪ Previous: Billing Guide for Anesthesiology assitand and Anesthesia time

Lumbar puncture Procedure code and Description

62270 T Spinal puncture, lumbar, diagnostic 0206 $373 $204

62272 T Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 0206 $373 $204

62273 T Injection, epidural, of blood or clot patch 0207 $672 $368

What is a Lumbar Puncture?

Fluoroscopy is a special form of X-ray that produces real-time video images, as opposed to pictures on film, making it possible to see internal organs and joints in motion. A lumbar puncture (also called a spinal tap) is a fluoroscopic procedure used to collect and look at the cerebrospinal fluid (CSF) surrounding the brain and spinal cord.

A lumbar puncture can help diagnose serious infections, such as

• Meningitis;
• Other disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis;
• Cancers of the brain or spinal cord.

Sometimes doctors use lumbar puncture to inject anesthetic medications or chemotherapy drugs into the cerebrospinal fluid.

Other names for a lumbar puncture (an LP):
• Spinal tap
• Spinal puncture
• Thecal puncture (thecal sac is a membrane of dura mater that surrounds the spinal cord and the cauda equina)
• Rachiocentesis (prefix “rachio-” indicating “spine”)

Other spinal punctures or punctures to obtain cerebral spinal fluid (CSF):

• Ventricular puncture (this is a puncture into a lateral ventricle of the brain)
• Cisternal puncture (this is a cervical vertebral puncture into the cisterna at the base of the brain)

Spinal Injection Procedures that May Be Done Without Fluoroscopy Interlaminar epidural steroid injections may be performed without fluoroscopy if performed at a certified or accredited facility by a provider with privileges to perform the procedure at that facility. The provider must decide whether to use fluoroscopy based on sound medical practice. To be payable, these spinal injections must include a facility place of service code and documentation that the procedure was performed at a certified or accredited facility. Procedure Code 62310 62311 62318 62319

Spinal Injection Procedures that Don’t Require Fluoroscopy Procedure Code 62270 62272 62273

Anesthesia Service Codes not an all-inclusive list

Procedure 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. See Modifier policy for a complete 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

Image Guidance: 77003 Fluoroscopy Image Guidance: Guidance: 77003 Fluoroscopy Fluoroscopy * Spine and Spinal Cord: Injection, Drainage, or Aspiration Procedure Section Guidelines

– Injection of contrast during fluoroscopic guidance and localization is an inclusive component in 62263, 62264, 66267, 62270-62273, 62280-62282, 62310- 62319.

A second issue relates to the reimbursement schedule. Most of the interventional procedures are grouped into Group II, diagnostic and therapeutic procedures with therapeutic procedures being reimbwsed at 7 5o/o of the applicable group rates of $130.00 and other diagnostic procedures at $168.00.

The following procedures are either listed in Group II C or D:

Procedure 62273 - injection, epidural, ofblood or clot patch

Procedure 62281 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, cervical or thoracic

Procedure 62282 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Procedure 6231,0 - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or'therapeutic substances; epidural or subarachnoid; cervical or thoracic

Procedure 62311 - - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or therapeutic substances; epidural or subarachnoid; lumbar, sacral (caudal)

↧

CPT code 00640, 01935, 01936 and 01991

November 15, 2016, 10:14 pm

≫ Next: Anesthesia and CRNA Services in a Critical Access Hospital (CAH)

≪ Previous: CPT code 62270, 62272, 62273

Procedure code and Description

00640 (Investigational) ANESTHESIA FOR MANIPULATION OF THE SPINE OR FOR CLOSED PROCEDURES ON THE CERVICAL, THORACIC OR LUMBAR SPINE

01935 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; DIAGNOSTIC

01936 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; THERAPEUTIC

01991 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); OTHER THAN THE PRONE POSITION

01992 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); PRONE POSITION

Additional Information

Monitored anesthesia (as defined by CPT codes 01991, 01992, 01935 and 01936) is considered not medically necessary when provided in conjunction with all of the Epidural Injections defined in this policy. Denials for anesthesia services will be reviewed only on appeal with supportive medical necessity documentation.

For additional information relating to medical policy regarding this service, please review the CareSource Medical Policy titled “Pain Management Interventional Procedures Policy”

Anesthesia Services Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness.

Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure code plus modifier codes. Surgery codes are not appropriate unless the anesthesiologist or Qualified Nonphysician Anesthetist is performing the surgical procedure.

An anesthesiologist, Qualified Nonphysician Anesthetist or an Anesthesia Assistant (AA) can provide anesthesia services. The anesthesiologist and the Qualified Nonphysician Anesthetist can bill separately for anesthesia services they personally perform. In cases of medical direction, both the anesthesiologist and the Qualified Nonphysician Anesthetist would bill Medicare for their component of the procedure. Each provider should use the appropriate anesthesia modifi er.

Note: If the surgery is non-covered, the anesthesia is also non-covered. Anesthesia procedure codes are organized as follows:

Area of the Body Head Neck Thorax (chest wall and shoulder girdle) Intrathoracic Spine and Spinal Cord Upper Abdomen Lower Abdomen Perineum Pelvis (except hip) Upper Leg (except knee) Knee and Popliteal Area Lower Leg (below knee, including ankle and foot) Shoulder and Axilla Upper Arm and Elbow Forearm, Wrist and Hand Radiological Procedure Burn Excisions or Debridement Obstetric

Other Procedure CPT Code Range

00100-00222

00300-00352

00400-00474

00500-00580

00600-00670

00700-00797

00800-00882

00902-00952

01112-01190

01200-01274

01320-01444

01462-01522

01610-01682

01710-01782

01810-01860

01916-01936

01951-01953

01958-01969

01990-01999

Description of Procedure or Service

Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation).

Background

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft-tissue adhesions with less force than would be required to overcome patient resistance or apprehension.

MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to treat (reduce) fractures (e.g., vertebral, long bones) and dislocations. MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spinal region, when standard care, including manipulation, and other conservative measures have been unsuccessful. MUA of the spine has been used in various forms since the 1930s. Complications from general anesthesia and forceful long-lever, high-amplitude nonspecific manipulation procedures resulted in decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival is attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.

MUA of the spine is described as follows: after sedation is achieved, a series of mobilization, stretching, and traction procedures to the spine and lower extremities is performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area if considered necessary to address the low back pain.

The MUA takes 15–20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners recommend performing the procedure on 3 consecutive days for best results. Care after MUA may include 4–8 weeks of active rehabilitation with manual therapy including SMT and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar

zygapophyseal and/or sacroiliac joints under fluoroscopic guidance (MUJA) and after epidural injection of corticosteroid and local anesthetic (MUESI). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these may be referred to as medicine-assisted manipulation.

This policy does NOT address the treatment of vertebral fractures or dislocations by spinal MUA. This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

When Spinal Anesthesia Under Anesthesia is not covered

• Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.

• Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions are considered investigational.

• Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain.

Policy Guidelines

Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. Evidence is insufficient to determine whether MUA improves health outcomes.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 22505, 00640

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

↧

Anesthesia and CRNA Services in a Critical Access Hospital (CAH)

November 24, 2016, 6:24 am

≫ Next: Pediatric anesthesia service CPT 99143, 99144 AND 99145

≪ Previous: CPT code 00640, 01935, 01936 and 01991

Payment for CRNA Pass-Through Services

If a CAH that meets the criteria for a pass-through exemption is interested in selecting the Method II option, it can choose this option for all outpatient professionals except the CRNA’s and still retain the approved CRNAs exemption for both inpatient and outpatient professional services of CRNAs. The CAH, with an approved exemption, can choose to give up its exemption for both inpatient and outpatient professional services of CRNAs in order to include its CRNA outpatient professional services along with those of all other professional services under the Method II option. By choosing to include the CRNAs under the Method II for outpatient services, it loses its CRNA pass-through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services.

All A/B MAC (A) payments for CRNA services are subject to cost settlement.

If a CAH that meets the criteria for a pass-through exemption is not interested in selecting the Method II option, the CAH can still receive the CRNA pass-through under the Standard Option (Method I). Below are the billing requirements for Method

Provider Billing Requirements for Method I

TOBs = 85X and 11X

Revenue Code 037X for CRNA technical services

Revenue Code 0964 for Professional services

HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 37X, CRNA technical service = Cost Reimbursement

Revenue Code 0964, CRNA professional service = Cost Reimbursement for both inpatient and outpatient

Deductible and coinsurance apply.

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.

Payment for Anesthesia Services by a CRNA (Method II CAH only)

Provider Billing Requirements for Method II Receiving the CRNA Pass-Through

TOB = 85X

Revenue Code 037X = CRNA technical service

Revenue Code 0964 = CRNA professional service

HCPCS Code = for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 037X, CRNA technical service = cost reimbursement

Revenue Code 0964, CRNA professional service = cost reimbursement

Deductible and coinsurance apply.

Provider Billing Requirements for Method II CRNA - Gave up Pass-Through Exemption (or never had exemption)

TOB = 85X

Revenue Code = 037X for CRNA technical service

Revenue Code = 0964 for CRNA professional service

Reimbursement - For dates of service on or after July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = based on 100 percent of the allowed amount when not medically directed or
50 percent of the allowed amount when medically directed.

Providers bill a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service on or after July 1, 2007

Identify anesthesia claims by HCPCS code range from 00100 through 01999

Non-medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15

Medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsurance) times 1.15

Reimbursement - For dates of service prior to July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of allowed amount (Use Anesthesia formula) for outpatient CRNA professional services.

Providers a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service prior to July 1, 2007

Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific anesthesia conversion factor (file name below).

The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.

If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.

Base Formula

Number of minutes divided by 15, plus the base units = Sum of base units and time Sum of base units and time times the conversion factor = allowed amount

Source

Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS

Conversion Factor = File - MU00.@BF12390.MPFS.CYXX.ANES.V1023

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.

CAH Outpatient Services Part B Deductible and Coinsurance

Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amounts unless waived based on statute.

For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100-04, Medicare Claims Processing Manual.

Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost-sharing - no coinsurance, deductible, copayment, or any other cost-sharing.

↧

Pediatric anesthesia service CPT 99143, 99144 AND 99145

December 2, 2016, 2:45 am

≫ Next: CPT code 00170 - Anesthesia intraoral procedures

≪ Previous: Anesthesia and CRNA Services in a Critical Access Hospital (CAH)

Pediatric Moderate (Conscious) Sedation

Effective January 1, 2006, Procedure codes 99141 and 99142 were deleted and have been replaced with Procedure codes 99143 (Moderate sedation services…provided by the same physician performing the diagnostic or therapeutic service…requiring the presence of an independent trained observer to assist in the monitoring of the patient’s…under 5 years of age, first 30 minutes intra-service time), 99144 (…age 5 years or older, first 30 minutes intra-service time), and add-on code 99145 (…each additional 15 minutes intra-service time).

• Claims for moderate sedation should be submitted hard copy indicating the medical necessity for the procedure. Documentation should also reflect pre- and post-sedation clinical evaluation of the patient.

• Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999).

• Moderate sedation is restricted to recipients from birth to age 13. (Exceptions to the age restriction will be made for children who are severely developmentally disableddocumentation attached must support this condition. No claims will be considered for recipients twenty-one years of age or older)

• Moderate sedation includes the following services (which are not to be reported/billed separately):

* * Assessment of the patient (not included in intraservice time);

* * Establishment of IV access and fluids to maintain patency, when performed;

* * Administration of agent(s);

* * Maintenance of sedation;

* * Monitoring of oxygen saturation, heart rate and blood pressure; and

* * Recovery (not included in intraservice time)

• Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.

• Louisiana Medicaid has adopted Procedure guidelines for procedures that include moderate sedation as an inherent part of providing the procedure. Louisiana Medicaid does not reimburse when a second physician other than the health care professional performing the diagnostic or therapeutic service provides the sedation. Claims paid inappropriately are subject to recoupment.

Additional Anesthesia Information

• CRNAs must place the name of their supervising doctor in Item 17 of the CMS 1500 or 837P claim form.

• Anesthesia time begins when the provider begins to prepare the patient for induction and ends with the termination of the administration of anesthesia.

• Time spent in pre- or postoperative care may not be included in the total anesthesia time.

• A surgeon who performs a surgical procedure will not also be reimbursed for the administration of anesthesia for the procedure.

• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.

• Anesthesia for arteriograms, cardiac catheterizations, CT scans, angioplasties and/or MRIs should be billed with the appropriate code from the Radiological Procedures subheading in the Anesthesia section of Procedure .

• Procedure code 00952 (Anesthesia for vaginal procedures…; hysteroscopy and/or hysterosalpingography) pends to Medical Review and must be submitted hardcopy with the anesthesia record attached.

When billed for anesthesia administered during a hysterosalpingogram, Procedure code 58340, the documentation attached must indicate:

* * medical necessity for anesthesia (diagnosis of mental retardation, hysteria, and/or musculoskeletal deformities
that would cause procedural difficulty) and

* * that the hysterosalpingogram (HSG) meets the criteria for that procedure (see the Medical Review section-Billing
Information)

• Anesthesia for dental restoration should be billed under Procedure anesthesia code 00170 with the appropriate modifier, minutes and most specific diagnosis code. Reimbursement is formula-based, with no additional payment being made for a biopsy. A provider does not have to perform a biopsy to bill this code.

• Anesthesia for multiple surgical procedures in the same anesthesia session must be billed on one claim line using the most appropriate anesthesia code with the total anesthesia time spent reported in Item 24G on the claim form.

The only secondary procedures that are not to be billed in this manner are tubal ligations and hysterectomies.

• Anesthesia claims with a total anesthesia time less than 10 minutes or greater than 224 minutes must be submitted hard copy with the appropriate anesthesia graph attached.

• Anesthesia claims for multiple but separate operative services performed on the same recipient on the same date of service must be submitted hard copy, with a cover letter indicating the above. The anesthesia graphs from the surgical procedures should be included and the claim with attachments should be submitted to Unisys at the address below.

• When anesthesia claims deny with error codes 749 (delivery billed after hysterectomy was done) or 917 (lifetime limits for this service have been exceeded), a new claim must be submitted to Unisys at the address below with a cover letter describing the situation.

↧

CPT code 00170 - Anesthesia intraoral procedures

January 4, 2017, 10:52 pm

≫ Next: cpt code 00840 -Anesthesia for Intraperitoneal procedures

≪ Previous: Pediatric anesthesia service CPT 99143, 99144 AND 99145

Use CPT code 00170 to bill general anesthesia

The Health Insurance Portability and Accountability Act of 1996 mandates that all professional anesthesia services performed on or after Sept. 1, 2002, be reported with CPT-4 anesthesia procedure codes (range *00100-*01999) and national modifiers.

The correct code to report general anesthesia for dental services under the medical program is:

Procedure Code Explanation

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

The medical criteria for the procedure are:

• Children under age four (i.e., through the end of their third year) are approved based on age alone.

• Older patients require a total of six or more teeth extractions, restorations or other procedures performed in two or more quadrants of the mouth, and one of the following:

– High-risk medical condition that does not permit the procedure to be performed safely under local anesthesia

– Infection that does not allow the use of local anesthesia

– Extensive orofacial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised

Billing Guide

00126, 00170, 01961 - Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, or cesarean deliveries: When modifiers QK or QY are used on claims with procedure codes 00126, 00170, or 01961, the services will be reimbursed at 60% of the West Virginia state Medicaid physician fee schedule.

00126, 00170, 00840, 00851, or 01961,- Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, lower abdominal surgery, tubal ligation, or cesarean deliveries: When modifier QX is used on claims with procedure codes 00126, 00170, 00840, 00851, or 01961, the services will be reimbursed at 40% of the West Virginia state Medicaid physician fee schedule.

CRNA Services and Modifier Combinations

Modifiers QZ and U1 must be submitted when a CRNA has personally performed the anesthesia services, is not medically directed by the anesthesiologist, and is directed by the surgeon. Modifiers QX and U2 must be submitted by a CRNA who provided services under the medical direction of an anesthesiologist.

Monitored Anesthesia Care

Anesthesiologists or CRNAs may use modifier QS to report monitored anesthesia care.

The QS modifier is an informational modifier, and must be billed with any combination of pricing modifiers for reimbursement.

30.2.4.4 Dental General Anesthesia Procedure code 00170 with modifier U3 should be used when billing for the appropriate reimbursement of dental general anesthesia.

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

General Modifiers Can use with CPT code 00170

The following anesthesia modifiers must be used for anesthesia services: - AA Anesthesia services personally performed by the anesthesiologist. The modifier “AA” may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence.

- AD Medical supervision by a physician: more than four concurrent anesthesia procedures;
- QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals;
- QX CRNA with medical direction by a physician or anesthesia assistant with medical direction by an anesthesiologist;
- QY Medical direction of one CRNA by an anesthesiologist; and
- QZ CRNA without medical direction by physician.

Note: Anesthesiologist assistants may use the modifier “QX” for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may use the “QY” modifier if he/she provides medical direction to an anesthesiologist assistant.

When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a covered oral surgery procedure for which there is not a surgical code, the anesthesia services must use code 00170 modified by the appropriate anesthesia modifier.

For the reimbursement of anesthesia services the provider must use the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier, and report the total anesthesia time in minutes.

Surgical CPT codes that include the administration of anesthesia in the description of that CPT code will only be reimbursed when an anesthesia CPT code in the range 00100-01999 is also coded on the claim. Certain CPT codes will not be reimbursed by CareSource because it is not considered to be a surgery or incident to another surgery.

↧

cpt code 00840 -Anesthesia for Intraperitoneal procedures

January 7, 2017, 10:58 pm

≫ Next: CPT code 81225, 81227, 81355

≪ Previous: CPT code 00170 - Anesthesia intraoral procedures

cpt code and Description

00840 Anesthesia for Intraperitoneal procedures in lower abdomen including laparoscopy

Billing Guide

Base units - 6 (Additional time may be billed in 15 minute increments = 1 unit)

00126, 00170, 00840, 00851, or 01961, Certified Registered Nurses Anesthetist (CRNA) during tympanotomy, intraoral procedures, lower abdominal surgery, tubal ligation, or cesarean deliveries: When modifier QX is used on claims with procedure codes 00126, 00170, 00840, 00851, or 01961, the services will be reimbursed at 40% of the West Virginia state Medicaid physician fee schedule

Explanation of Updates

Section 292.440 has been revised to correct errors in billing instructions effective October 13, 2003. Information that is no longer applicable to this program has been deleted. This section of the manual has been reformatted for clarification and readability. Information has been added to notify providers that anesthesia procedure codes with a base of 4 or less are eligible to be billed with a second modifier, 22, referencing surgical field avoidance.

Information previously included in Section 292.440, part A has been moved to an added part of this section, part C. The information in part C has been revised to delete national CPT procedure code 00840 as an appropriate crosswalk for local code Z9940. Locally assigned procedure code Z9940 is the correct procedure code when billing anesthesia services for abdominal hysterectomy.

The description for Z9940 has been changed to “anesthesia for abdominal hysterectomy.” Information previously included in part B of section 292.440 has been moved to an added part of this section, part D. Information in part D has been revised to delete procedure code 00855 and add procedure codes 01962 and 01963 as replacement codes.

Section 292.447 includes minor changes to the example of a completed claim for clarification. Section 292.730 includes information regarding the billing of professional and technical components for covered laboratory and radiology services and use of new modifiers, TC for the technical component and 26 for the professional component.

Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes have already been incorporated.

00840 Required to name each procedure done on females only, by surgeon in “Procedures, Services or Supplies” column.

ASA Codes Associated with CPT Codes That May Require Prior Authorization

00402 Anesthesia for reconstructive breast procedures (reduction, augmentation, muscle flaps)
00580 Anesthesia for heart transplant or heart-lung transplant
00796 Liver transplant (recipient)
00840 Anesthesia for intraperitoneal procedures in lower abdomen (hysterectomy and sterilization)
00846 Anesthesia for radical hysterectomy
00848 Anesthesia for pelvic exenteration

↧