Saturday, July 25, 2020

Anesthesia Billing overview- Reimbursement formulas with modifier

Anesthesia Services

Anesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999, excluding 01953 and 01996, and are reimbursed as time-based using the Standard Anesthesia Formula. Refer to the attached Anesthesia Codes list for all applicable codes. For purposes of this policy the code range 00100-01999 specifically excludes 01953 and 01996 when referring to anesthesia services. CPT codes 01953 and 01996 are not considered anesthesia services because, according to the ASA RVG®, they should not be reported as time-based services.

Modifiers Required

Anesthesia Modifiers

All anesthesia services including Monitored Anesthesia Care must be submitted with a required anesthesia modifier in the first modifier position. These modifiers identify whether a procedure was personally performed, medically directed, or medically supervised. Consistent with CMS, UnitedHealthcare will adjust the Allowed Amount by the Modifier Percentage indicated in the table below.

Reimbursement Percentage

AA Anesthesia services performed personally by an anesthesiologist. 100%

AD Medical supervision by a physician: more than four concurrent anesthesia procedures. *For additional information, refer to Standard Anesthesia Formula with Modifier AD under Reimbursement Formula 100%

QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. 50%

QX Qualified nonphysician anesthetist with medical direction by a physician 50%

QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist 50%

QZ CRNA service; without medical direction by a physician. 100%

Additional anesthesia billing guidelines to consider::

• Gateway processes anesthesia services based on anesthesia procedure codes only.

• All services must be billed in minutes. Fractions of a minute should be rounded to whole minutes (30 seconds or greater: round up; less than 30 seconds: round down).

• Physical status modifiers, P1-P6, will not allow any additional payment. These are informational modifiers only and should be submitted after the pricing modifier.

• The claim should include ONLY the primary anesthesia code except when there is an addon code that should be reported along with the primary anesthesia service.

• If you provide pain management services, continue to bill with surgical codes.

• If you provide medical procedures such as Swan Ganz, Laryngoscopy Indirect with Biopsy, Venipuncture Cutdown, Placement of Catheter or Central Vein, then continue to bill with the medical procedure code.

• When billing OB anesthesia codes 01960, 01961, 01962, 01963, and 01967 you do not need to add an additional hour for patient consultation. The Department of Human Services has already added 4 to the relative value unit for these codes.

• When billing anesthesia for all obstetrical procedures, use the anesthesia procedure codes as defined in the Anesthesia section of the CPT4 manual. Should you have any questions about this communication please contact your Provider Relations Representative or Gateway’s Customer Service Department. Customer Service is available 8:30 am to 4:30 pm Monday through Friday by calling 1-800-392-1147 for Medicaid or 1-800-685-5209 for Medicare Assured.

Preventative Medicine and Sick Visits

As per AMA CPT Guidelines, Gateway shall allow reimbursement for a medically necessary sick visit Evaluation and Management (E/M) Service at the same visit as a Preventative Medicine Service (CPT 99381

– 99429) when it is clinically appropriate. Providers shall use CPT codes 99201 – 99215 to report a sick visit E/M with CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the Preventative Medicine code reported. If modifier 25 is not appended, the sick visit will deny. Please verify with the Medicaid Fee Schedule for reimbursable Preventative Medicine Service codes.

Modifier 25 vs Modifier 57

As per AMA CPT Guidelines, Gateway will reimburse E/M Services on the same day as a global surgical procedure for the following circumstances: Modifier 25 – Significant evaluation and management service by same physician on date of global procedure

• E/M Service that is significant and separate on the day of a procedure with a 0 or 10-day global surgical periodModifier 57 – Decision for surgery made within global surgical period

• E/M Service that is the decision for surgery on the day of or on the day before a procedure with a 90-day global surgical procedure

The modifiers should be appended to the E/M Service. Absence of the modifiers will cause the E/M Service will deny as global to the procedure.

Reimbursement Formula

Base Values:

Each CPT anesthesia code is assigned a Base Value by the ASA, and UnitedHealthcare uses these values for determining reimbursement. The Base Value of each code is comprised of units referred to as the Base Unit Value.

Time Reporting: Consistent with CMS guidelines, UnitedHealthcare requires time-based anesthesia services be reported with actual Anesthesia Time in one-minute increments. For example, if the Anesthesia Time is one hour, then 60 minutes should be submitted.

Reimbursement Formulas:

Time-based anesthesia services are reimbursed according to the following formulas: Standard Anesthesia Formula without Modifier AD* = ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage. Standard Anesthesia Formula with Modifier AD* = ([Base Unit Value of 3 + 1 Additional Unit if anesthesia notes indicate the physician was present during induction] x Conversion Factor) x Modifier Percentage.

*For additional information, Refer to Modifiers.

Qualifying Circumstances

Qualifying circumstances codes identify conditions that significantly affect the nature of the anesthetic service provided. Qualifying circumstances codes should only be billed in addition to the anesthesia service with the highest Base Unit Value. The Modifying Units identified by each code are added to the Base Unit Value for the anesthesia service according to the above Standard Anesthesia Formula.



Anesthesia Services Provided by the Operating Surgeon

Local infiltration, digital block, or topical anesthesia administered by the operating surgeon is included in the unit value for the surgical procedure.

If the attending surgeon administers anesthesia, the value shall be the lesser of the basic unit value without benefit for time or 25 percent of the total dollar value of the surgery. (See modifier 47\ for guidelines on reporting administration of anesthesia by the attending surgeon.)

Major regional anesthesia administered by the surgeon, such as a spinal epidural or major peripheral nerve block, shall be reimbursed the basic anesthesia value only without benefit for time. (See modifier 47 for guidelines on reporting administration of anesthesia by the attending surgeon.)

If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so indicate with the use of a modifier NT for “no time.”

Nerve Block

For diagnostic or therapeutic nerve block, see 62310–62319 and 64400–64530.

For diagnostic or therapeutic nerve blocks performed by the surgeon, anesthesiologist, or CRNA, only one reimbursement per procedure shall be allowed, regardless of the time required (e.g., see codes 62310–62319, 64400–64530).

Field Avoidance

Any procedure around the head, neck, or shoulder girdle that requires field avoidance or any procedure compromising the anesthesia administration (e.g., requiring a position other than supine or lithotomy) has a minimum basic value of 5.0 units regardless of any lesser basic value assigned to such procedures. In this case, modifier 22 is required.

Multiple Procedures

Anesthesia reimbursement for multiple procedures is based on the procedure with the highest base value, plus modifying units (if appropriate), plus total time units for all combined surgical procedures.

No additional base value shall be reimbursed for anesthesia rendered during additional surgical procedures (other than the primary procedure) performed on the same day during the same operative setting.

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