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California Medical Bill Reviewer Certification

California Medical Bill Reviewer Certification. Unit 2: Official Medical Fee Schedule Module 4: Anesthesia. Overview. Hi! In this module, you will learn about anesthesia services, how they are reimbursed, and the circumstances that can affect reimbursement.

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California Medical Bill Reviewer Certification

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  1. California Medical Bill Reviewer Certification Unit 2: Official Medical Fee Schedule Module 4: Anesthesia

  2. Overview Hi! In this module, you will learn about anesthesia services, how they are reimbursed, and the circumstances that can affect reimbursement. Then, you will learn how anesthesia services are used for pain management services. Let’s start by discussing general anesthesia guidelines and how anesthesia services are reimbursed... Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services • Modifiers: • Basic Modifiers • Physical Status Modifiers • Qualifying Circumstances Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services

  3. What is Anesthesiology? • Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain. Anesthesia includes the use of: Anesthesia also involves: • Sedative drugs • Analgesic drugs • Hypnotic drugs • Anti-emetic drugs • Respiratory drugs • Cardiovascular drugs • Preoperative assessment • Intra-operative patient management • Postoperative care • Autonomic, neuromuscular, cardiac, and respiratory physiology

  4. The anesthesia section in the OMFS ranges from 00100-01999. Anesthesia codes do not correspond one-to-one with surgery codes because multiple surgery codes may crosswalk to the same anesthesia code. For example, CPT 01382 is used for anesthesia services for any arthroscopic procedure on the knee joint. Anesthesia Guidelines Therefore, 17 surgery codes correspond to this single anesthesia service. • Single anesthesia codes correspond to multiple surgical codes because the anesthesiologist performs the same tasks for any of the arthroscopic knee services and the only variation may be time.

  5. Anesthesia Services • Anesthesiologists may bill for a variety of services and methods of anesthesia. Anesthesia Methods: Anesthesia services include: • General anesthesia • Moderate sedation • Regional anesthetic • Pre-operative visit with the patient. • Ordering and giving medication. • Monitoring the patient’s vital signs and level of sedation.

  6. Procedures not Separately Reimbursable • Just like other procedures, some anesthesia procedures can be billed separately, while other procedures cannot be billed separately. Services not billed separately include: • Pre and post-operative routine visits. • Administration of fluids, including blood. • Usual monitoring services such as: EKG, temperature, blood pressure, oximetry, capnography, and mass spectrometry. • The system is automated to deny all non-invasive monitoring services billed with an anesthesia code.

  7. In contrast, anesthesiologists can bill for invasive procedures. Separately Reimbursable Procedures Some of these invasive procedures include: • Insertion of a central venous catheter • Esophageal catheter • Swan-Ganz catheter

  8. Anesthesiologists are reimbursed per a base unit value assigned to each anesthesia code andby units of time. Anesthesia Reimbursement For up to 4 hours of service: 1 Time Unit = 15 minutes After 4 hours of service: 1 Time Unit = 10 minutes • Five minutes or more is considered significant enough for the final unit. • Calculations are automated but may be required in a manual pricing situation. Let’s take a look…

  9. Anesthesia Reimbursement CPT 00630: Anesthesia for lumbar spine surgery Duration: 5 hours, 35 minutes Base Units: 8 What happens to the extra 5 minutes? TIME UNITS: First 4 hours: TIME UNITS: Remaining 1 hr, 35 minutes: 4 hours = 240 minutes 335 – 240 = 95 minutes 240 minutes/15 minutes per unit 95 minutes/10 minutes per unit = 16 units = 9 units + 5 extra minutes Base Units + Time Units = Total Units 8 + 16 + ? = ?

  10. Remember, 5 minutes or more is considered enough for a final unit. Therefore, we round the remaining 5 minutes of time up to count as 1 whole unit! Anesthesia Reimbursement TIME UNITS: Remaining time: 335 – 240 = 95 minutes 95 minutes/10 minutes per unit = 9 + 5 extra minutes = 10 units Base Units + Time Units = Total Units 8 + 16 + 10 = 34

  11. Where did the last 3 minutes go? Remember, only 5 minutes or more can be reimbursed as a final unit. So, in this case, we round down to 60 minutes, or 4 units! Anesthesia Reimbursement CPT 01202: Anesthesia for hip arthroscopy Duration: 1 hours, 3 minutes Base Units: 4 TIME UNITS: 1 hour, 3 minutes: 1 hour, 3 minutes = 63 minutes 60 minutes/15 minutes per unit = 4 units Base Units + Time Units = Total Units 4 + 4 = 8

  12. Modifiers Now that you are familiar with the basics of anesthesia, let’s discuss how modifiers and extreme circumstances can alter reimbursement. We will begin by discussing a few basic anesthesia modifiers... Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services • Modifiers: • Basic Modifiers • Physical Status Modifiers • Qualifying Circumstances • Modifiers: • Basic Modifiers

  13. As you know, each section of the OMFS has a list of modifiers that pertain to those services. Modifiers We will discuss the following modifiers: • Modifier –36 • Modifier –47 • Modifier –48 • Recall that modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. See the OMFS for a complete list of modifiers!

  14. Modifier -36 • In some instances, special circumstances warrant an increase in the basic value of specific procedures. Procedures with a basic value of three or less base units which: • Require endotracheal intubation for prone or other difficult positions • Require surgical field avoidance • Are performed for medical necessity -36 Anesthesia Procedures: This modifier increases the basic value for these procedures to four base units. Other applicable modifiers also apply. ...may warrant an additional charge.

  15. Modifier -47 • In some instances, anesthesia is provided by a surgeon, rather than an anesthesiologist. -47Anesthesia by Surgeon: regional anesthesia provided by a surgeon. No time units are applied. It is important to realize that Modifier –47 should only be billed with surgical codes, not anesthesia codes.

  16. Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, although they must be under the supervision of an anesthesiologist. Certified Registered Nurse Anesthetists • To be eligible for reimbursement, the anesthesiologist must be within hearing and visual range, and cannot supervise more than 2 rooms, or administer anesthesia himself. Both the anesthesiologist and the CRNA are reimbursed. The anesthesiologist is paid for the base units anda reduced number of time units. The CRNA is paid the remainder of the total reimbursement of an anesthesiologist performing the service. • Lastly, the anesthesiologist must be involved in the medical direction of the patient, including pre and post-operative care.

  17. Modifier –48 indicates that a CRNA performed anesthesia services. Modifier -48 • 48 Reduced Anesthesia Value for Supervising Anesthesiologist: Reimbursement for the supervising physician shall be for the basic value of the procedure plus one unit per hour or fraction thereof for the duration of the anesthesia. Total reimbursement to the CRNA and supervising anesthesiologist shall not exceed the listed value of the service if performed by an anesthesiologist.

  18. Suppose Dr. Jones supervises two operating rooms with CRNAs giving anesthesia in each. He does not administer the anesthesia himself. Certified Registered Nurse Anesthetists Operating Room 1 Dr. Jones Operating Room 2

  19. Certified Registered Nurse Anesthetists Operating Room 1 Operating Room 2 Dr. Jones Duration: 1 hour, 15 minutes Base Value = 4 Duration: 45 minutes Base Value = 6

  20. Certified Registered Nurse Anesthetists Operating Room 1 Operating Room 2 Duration: 1 hour, 15 minutes Base Value = 4 Duration: 45 minutes Base Value = 6 75 minutes = 5 units 45 minutes = 3 units Now you try... How many units can be reimbursed to the anesthesiologist and the CRNA? Total Units = 9 Total Units = 9 Anesthesiologist: 1 unit/hour (or fraction thereof) = 2 time units Anesthesiologist: 1 time unit Anesthesiologist Total = 1 + 6 = 7 Anesthesiologist Total = 2 + 4 = 6 CRNA: 9 – 6 = 3 Units CRNA: 9 – 7 = 2 Units

  21. Physical Status Modifiers In addition to standard modifiers, there are other modifiers, known as physical status modifiers, which can affect the reimbursement of anesthesia services. Let’s take a look…

  22. Anesthesia complicated by the patient’s condition may be additionally reimbursed if documentation supports the presence of significant disease. Physical Status Modifiers • These significant complications are indicated by physical status modifiers. While hypertension and diabetes are not considered significant enough to warrant use of the higher level physical status modifiers, conditions such as: • Congestive heart failure • Emphysema • Uncontrolled epilepsy ...are reimbursable.

  23. Physical Status Modifiers • The physical status modifiers and their values are:

  24. Remember, 195 minutes/15 min. per unit = 13 That leaves 10 minutes remaining. So, we round up to account for 1 extra unit, for a total of 14 time units! Anesthesia Reimbursement CPT 01402: Anesthesia for total knee replacement Duration: 3 hours, 25 minutes Complication: Patient has congestive heart failure (P3: 1 unit) Base Units: 7 TIME UNITS: 3 hours, 25 minutes: 3 hours, 25 minutes = 205 minutes 205 minutes/15 minutes per unit = 13 units + 10 extra minutes Base Units + Time Units + P3 Modifier Units= Total Units 7 + 14 + 1 = 22

  25. Some providers will attach a physical status modifier to all anesthesia services, while others will only attach those with unit values greater than zero. It is the processor’s responsibility to verify that documentation justifies the addition of the payable modifiers. Physical Status Modifiers Either method is acceptable and the system is automated to pay the modifier.

  26. Qualifying Circumstances As you know, physical status modifiers indicate significant complications. Similarly, there are special codes that indicate other extreme circumstances that can affect the reimbursement of anesthesia services. Let’s take a look…

  27. You have probably realized that there are certain circumstances which make giving anesthesia much more difficult. If the patient is extremely old or extremely young, the reaction to the anesthetic medications may be very different and must be monitored more closely. Qualifying Circumstances • Certain surgical procedures, such as cardiovascular or intracranial surgery, require lowering the blood pressure or body temperature significantly to reduce bleeding. These circumstances are known as qualifying circumstances, and are billed in addition to anesthesia services.

  28. Qualifying Circumstances • Qualifying circumstances are indicated by special codes, not modifiers. Qualifying Circumstance codes include: • 99100 – Anesthesia for patient of extreme age, under one year or over seventy. • 99116 – Anesthesia complicated by utilization of total body hypothermia. • 99135 – Anesthesia complicated by utilization of controlled hypotension. • 99140 – Anesthesia complicated by emergency conditions (specify).

  29. It is critical that documentation support the addition of qualifying circumstances. The age of a patient is easily verified to confirm an instance of “extreme age.” Qualifying Circumstances In contrast, hypothermia can only be justified if, in the report, there is documentation stating that a hypothermia pad or blanket was placed under the patient and used to drop the body temperature.

  30. You probably realize that like other providers, anesthesiologists can incorrectly bill for certain codes. Qualifying Circumstances Qualifying circumstance code 99135 is often incorrectly billed by anesthesiologists who simply keep a patient’s hypertension under control or lower the blood pressure slightly to minimize bleeding. 99135 should only be reimbursed if documentation shows a significant reduction in the blood pressure—at least 20 points—for delicate surgery such as intracranial operations.

  31. Pain Management Now that you are familiar with how anesthesia is generally used, let’s discuss how it can be used for pain management. Part II: Pain Management Services • Post-operative Pain Control • Chronic Pain Control Part II: Pain Management Services • Post-operative Pain Control • Chronic Pain Control

  32. Pain Management Services • Pain management occurs in two distinct circumstances: Post-operative Pain Control Chronic Pain Control Let’s take a look…

  33. This is because the service includes the anesthetic and all monitoring necessary to bring the patient safely through the surgery, regardless of the type of anesthetic. Pain Management Services • If a spinal, epidural, or regional anesthetic is used for anesthesia during a surgery instead of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.

  34. Post-operative Pain Control Post-operative Pain Control However, if a general anesthetic is given, making the patient unconscious, and the anesthesiologist gives an epidural or regional block for post-operative pain control in addition to the anesthesia given for the surgery, it can be billed separately.

  35. Post-operative Pain Control Example 1 Example 2 Bob Smith is having a meniscectomy performed in his right knee. Bob Smith is having a meniscectomy performed in his right knee. He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with an epidural anesthetic, making him numb from the waist down, and some mild IV sedation for anxiety control. He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with a general anesthetic because his anxiety level is so high. In addition, the anesthesiologist will insert an epidural catheter for pain control in the 24 hours following surgery. The anesthesiologist will code her services with 01382 for basic value and time but will not bill separately for the epidural insertion. The catheter insertion is separatelyreimbursed because it is not part of the anesthetic for the surgery. The anesthesiologist may not bill 01996 for pain control management on the day of surgery.

  36. In this case, it is part of the global surgery package. Post-operative Pain Control Just like other procedures, the surgeon cannot bill separately for pain control services, such as inserting a pain pump catheter, if it is performed as part of the surgery.

  37. In chronic pain management, anesthesiologists that specialize in pain control may see the patient for a single or a series of injections, either into a joint or body area, or into the epidural space. They may also employ non-injection methods of pain control such as biofeedback, physical therapy, and counseling. Chronic Pain Control Chronic Pain Control However, the most common treatment is injection.

  38. In California, like any other specialty who performs these services, these injections are billed and reimbursed as Type of Service (TOS) 2, which is surgery. Chronic Pain Control • If these services are billed as TOS 7, which is anesthesia, the processor must change the TOS to reflect that this is a surgical service.

  39. Anesthesiologists often used the American Society of Anesthesiologists (ASA) Relative Value Guide to bill for particular services. This reference guide lists the recommended base values for each procedure. Chronic Pain Control Often, anesthesiologists will mistakenly indicate the anesthesia base value in the units field on the bill. Remember, the bill review system already calculates the base value associated with a procedure.

  40. Unfortunately, all the above scenarios are viable possibilities. Chronic Pain Control • As you can see, when reviewing bills, it is important to determine the type of units and verify that they coincide with the service provided. If multiple units are billed, the processor must determine if the provider has: • performed multiple injections • billed for time units • indicated the anesthesia base value of the service in the unit field

  41. Chronic Pain Control Example Suppose a provider bills CPT 20610: large joint injection, for 3 units. As a processor, you should ask, “Is he billing for 3 injections or 3 time units? Or, is this the base value?" Only documentation can verify if this represents injections of both hips and one knee, for a total of 3 injections... ...or a single injection took the anesthesiologist 45 minutes, for a total of 3 time units. Let’s take a look…

  42. Chronic Pain Control 3 Joint Injections: left hip, right hip, & right knee The lines are separated, and the procedures are reimbursed at multiple procedure cascade. 3 Injections Left hip: 20610 x 100% of FS value Right hip: 20610 x 50% of FS value Right knee: 20610 x 25% of FS value

  43. Chronic Pain Control Single large joint injection representing time units or ASA base value The processor will need to change the unit field to 1 and the TOS to 2 to represent the actual service performed. 3 Time Units 1 injection Billed: 20610, TOS 7, Units: 3 Paid: 20610 x 100% of FS value TOS 2, Units: 1

  44. If multiple types of injections are performed, they are reimbursed at multiple procedure cascade. If the provider appeals the recommendation, he is educated on multiple cascade logic, which avoids duplicating reimbursement for overhead, pre-operative, and post-operative care. Chronic Pain Control Example: 62278 lumbar epidural: 100% FS 64440 injection paravertebral nerve: 50% FS 20550 trigger point injection: 25% FS

  45. A common error in pain management occurs when providers bill for an E & M service each time the patient comes in for an injection. Pain Management Services If a pattern, such as weekly visits is obvious, it is unlikely each visit was a significant, separately identifiable service and not just routine questioning about pain level. Unless the provider is assessing the patient’s progress in detail, treating an additional condition, or teaching or counseling the patient extensively, the E/M service is included in the injection procedure payment.

  46. How to calculate anesthesia reimbursements. Anesthesia: Services and Procedures Modifiers: How basic and physical status modifiers affect reimbursement. How post-operative pain control services are reimbursed. What constitutes qualifying circumstances. How chronic pain control services are reimbursed. Summary

  47. Module 4 Quiz Click on the link to go directly to the quiz. Feel free to review any of the material before you move on. Good Luck! Quiz: U2M4: Anesthesia

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