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Anesthesia (anest)

By Marjorie Peterson,2014-12-03 16:57
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Anesthesia (anest)

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    Anesthesia 1

This section is to assist providers in completing claims for anesthesia services. Medi-Cal has not adopted

    the “qualifying circumstances” codes (99100 – 99140). Claims submitted with these codes will be denied or returned to the provider for correction. For additional help, refer to the Anesthesia Billing Examples

    section of this manual.

Billing Anesthesia Services Anesthesia services (CPT-4 codes 00100 01999) are reimbursed

    when medically necessary. To bill for anesthesia services, use the

    five-digit CPT-4 code applicable to the procedure with the appropriate

    modifier. For anesthesia modifiers, see Modifiers: Approved List in

    this manual and the anesthesia modifiers charts in this section.

    Billing in 15-Minute Increments To bill anesthesia time units, enter the number of 15-minute of Anesthesia Time increments of anesthesia time in the Service Units/Days or Units box

    on the claim form, using the same billing line as the procedure code.

    Each 15-minute increment equals one time unit. Increments of time

    less than five minutes are not reimbursable except when the total

    anesthesia time being billed is less than five minutes. For more

    information, see the “Total Anesthesia Time Unit: Less Than Five

    Minutes” section.

    Total Anesthesia Time Unit: The last anesthesia time increment rendered may be rounded up to a More Than Five Minutes whole unit if it equals or exceeds five minutes. If the last anesthesia

    time increment provided is less than five minutes, it may not be billed

    as an additional anesthesia time unit.

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Time Unit Billing Examples Time unit examples:

    ; For 49 minutes of anesthesia time actually spent with the

    patient, enter 3 in the Service Units/Days or Units box.

    (The four-minute increment is not reimbursable.)

    ; For 80 minutes of anesthesia time actually spent with the

    patient, enter 6 in the Service Units/Days or Units box.

    (The five-minute increment is reimbursable.)

     Note: Do not include the base units for the procedure performed

    since the base unit payment is automatically included in the

    reimbursement rate. Billing for the base units could be

     considered a fraudulent billing practice.

Start, Stop and Total Claims billing for more than 40 units of time (10 hours) require that an

    Anesthesia Time anesthesia report be attached to the claim. The anesthesia report

    must include anesthesia start, stop and total times.

    CPT-4 Code 01967 For CPT-4 code 01967 (neuraxial labor analgesia/anesthesia for Billing Requirements: planned vaginal delivery [includes any repeat subarachnoid needle

    placement and drug injection and/or any necessary replacement of an

    epidural catheter during labor]), all claims of 20 units or more require

    that an anesthesia report be attached.

    Note: Claims for 19 units or less for code 01967 do not require

    detailed documentation on the claim form or an attachment

    “Time in Attendance” If billing for obstetrical regional anesthesia (CPT-4 code 01967), With the Patient in addition to the documentation requirements noted above, providers

    also must document “time in attendance” on the attached anesthesia

    report. Claims without such documentation will be denied. Only time

    in attendance with the patient may be billed.

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    “Time in attendance” is time when the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) monitors the patient receiving neuraxial labor analgesia, and the anesthesiologist or CRNA is readily and immediately available in the labor or delivery suite. If the actual time in attendance is less than the total quantity billed (in either the Service Units or Days or Units box), the claim will be reimbursed for

    the time in attendance with the patient. If two or more patients receive neuraxial analgesia concurrently, no more than four total time units per hour may be billed and must be apportioned among the claims, including claims to other insurance carriers.

    Example: Patients A and B receive overlapping labor analgesia: Patient A from 0500 to 1415 and Patient B from 0930 to 1245. See the following sets of instruction to bill for patient A and patient B.

Patient A claim completion instructions:

Field/Claim Type Enter

    Service Units field (Box 46) on the 31

    UB-04 claim

    Days or Units field (Box 24G) on the

    CMS-1500 claim

    Remarks field (Box 80) on the UB-04 SEE

    claim ATTACHMENT

    Reserved for Local Use field (Box 19) on

    the CMS-1500 claim

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     Required documentation will not fit in the designated area of the claim,

    so providers should enter the words “See Attachment” in the Remarks

    field (Box 80)/Reserved for Local Use field (Box 19) of the claim. For

    this example providers would submit the following exact statement on

    an attachment to the claim (following specific instructions under

    “Attachments” in the Forms: Legibility and Completion Standards

    section of this manual):

     Epidural anesthesia start time: 0500. Stop time: 1415.

    Time in attendance: 458 minutes (0500 0930 = 270 minutes;

    0930 1245 = 195 minutes, divided by 2 for overlapping

    time = 98 minutes; 1245 1415 = 90 minutes. 270+98+90 = 458)

    Patient B claim completion instructions:

    Field/Claim Type Enter

    Service Units field (Box 46) on the 7

    UB-04 claim

    Days or Units field (Box 24G) on the

    CMS-1500 claim

    Remarks field (Box 80) on the UB-04 SEE

    claim form ATTACHMENT

    Reserved for Local Use field (Box 19) on

    the CMS-1500 claim

     Required documentation will not fit in the designated area of the claim,

    so providers should enter the words “See Attachment” in the Remarks

    field (Box 80)/Reserved for Local Use field (Box 19) of the claim. For

    this example providers would submit the following exact statement on

    an attachment to the claim (following specific instructions under

    “Attachments” in the Forms: Legibility and Completion Standards

    section of this manual):

     Epidural anesthesia start time: 0930. Stop time: 1245. Time in

    attendance: 98 minutes (0930 1245 = 195 minutes, divided by 2

    to split overlapping time = 98 minutes).

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Obstetrical Anesthesia Providers billing codes 01958, 01960 01963, 01965, 01966, 01968

    Documentation or 01969 for general anesthesia must document “start-stop” and total

    times on an attached anesthesia report only if the claim is for more

    than 40 units of time (10 hours). Providers billing these codes for

    regional or both general and regional anesthesia must document “time

    in attendance” (in addition to “start-stop” times for general anesthesia,

    if billed for both) on the anesthesia report.

    Billing Obstetrical Anesthesia Add-on codes must be billed in conjunction with the primary Add-On Codes anesthesia code. For an example, refer to the Anesthesia Billing

    Examples section of this manual.

    Total Anesthesia Time Unit: The preceding policy applies to all anesthesia services, except when Less Than Five Minutes the total anesthesia time being billed is less than five minutes. In

    these situations, one increment of anesthesia time is reimbursable.

     When billing for anesthesia time that is less than five minutes, enter 1

    in the Service Units/Days or Units box of the claim. Do not include the

    base unit for the procedure performed. Refer to the Rates: Maximum

    Reimbursement section in this manual for information about how

    anesthesia reimbursement is calculated.

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    Billing Multiple Anesthesia When two or more modifiers are necessary to identify the anesthesia Modifiers services, use modifier 99 with the appropriate five-digit CPT-4

     anesthesia code and explain the applicable modifiers in the Remarks

    field (Box 80)/Reserved for Local Use field (Box 19) of the claim or as

    an attachment. For an example, refer to the Anesthesia Billing

    Examples section of this manual.

    Surgical and Obstetrical Operating surgeons and obstetricians providing their own regional Anesthesia anesthesia (for example, caudal or epidural) must bill the anesthesia

    on a separate claim line from the surgical services. Bill using the

     five-digit CPT-4 surgery code with modifier 47. Reimbursement for

     the service will be the basic unit value for anesthesia for the procedure

    without the added value of the duration of the anesthesia.

     Local infiltration, uterine paracervical or pudendal block, digital block

    or topical anesthesia administered by the operating surgeon or

    obstetrician are included in the reimbursement for the surgical or

    obstetrical procedure itself and are not separately reimbursable.

    Elective Sterilization Anesthesiologists billing for the anesthesia time associated with an

    elective sterilization procedure must bill with either CPT-4 code 00851

    or 00921. See the Sterilization section in the appropriate Part 2

    manual for sterilization Consent Form (PM 330) requirements.

    Tubal Ligations: A postpartum tubal ligation performed in connection with a vaginal Vaginal Delivery delivery is considered a separate procedure. The anesthesia for the

    tubal ligation must be billed with CPT-4 code 00851 (anesthesia for

    intraperitoneal procedures in lower abdomen including laparoscopy;

    tubal ligation/transection).

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    Tubal Ligations: Anesthesiologist time billed for a tubal ligation performed during a Cesarean Delivery cesarean section should include the tubal ligation anesthesia by

    adding one (1) additional anesthesia time unit to the anesthesia time

    units for the cesarean section procedure (CPT-4 code 01961 or

     01968). (For an example, refer to the Anesthesia Billing Examples

    section of this manual.)

    Hysterectomy Anesthesiologists billing for the anesthesia time associated with a

    hysterectomy must provide a copy of the hysterectomy consent form,

    regardless of the CPT-4 procedure code billed. Codes that always

    require a hysterectomy consent form are 00846, 00848, 00944, 01962,

    01963 and 01969. See the Hysterectomy section in the appropriate

    Part 2 manual for hysterectomy consent form requirements.

Procedures Billed Only for CPT-4 procedure codes 62267 62273, 62280 62287,

    Diagnostic and Therapeutic 62290 62297, 62310, 62311, 62318, 62319, 64400 64439 and

    Services 64444 64530 are used only for billing injection, drainage or

     aspiration procedures for diagnostic or therapeutic services.

     Anesthesiologists performing these diagnostic and therapeutic

     services are acting as the primary surgeon and should bill these

     CPT-4 codes with modifier AG. These codes should not be billed with

     an anesthesia modifier.

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    Normal, Uncomplicated All anesthesia claims require a modifier. Failure to use the applicable Anesthesia Modifiers modifier will result in the claim being returned to the provider for

    correction.

     Modifier P1 must be billed with the appropriate five-digit CPT-4

    anesthesia code to identify a normal, uncomplicated anesthesia

    provided by a physician.

Certified Registered Nurse Refer to “Anesthesia Supervision” on a following page in this section

    Anesthetist (CRNA) for information about billing for Certified Registered Nurse Anesthetist

    (CRNA) services.

    Multiple Modifiers If more than one modifier is necessary, bill with modifier 99 (multiple

    modifiers) and list the appropriate modifiers in the Remarks field

    (Box 80)/Reserved for Local Use field (Box 19) of the claim.

Prone Position or Modifier 22 (increased procedural services) should be used only for

    Surgical Field anesthesia procedures with base units of three or less. These

    Avoidance Modifier techniques are included in the anesthesia base units for codes with a

    base value greater than three.

    Services Included Medi-Cal does not separately reimburse anesthesiologists for In Basic Rate equipment necessary to render anesthesia or the interpretation of

    laboratory findings (such as blood gases or ECG) normally used by

    them in administering anesthesia. Reimbursement for these services

    is included in the reimbursement for the basic rate.

    The complete evaluation routinely performed prior to the

    administration of anesthesia also is included in the basic rate. When

    billing consultation services (CPT-4 codes 99241 99275) and

    anesthesia services for the same recipient, by the same provider, for

    the same date of service, providers must state that the service was an

    actual consultation and not the complete pre-anesthesia evaluation in

    the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of

    the claim or as an attachment.

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    Separately Reimbursable Medi-Cal separately reimburses for the following anesthesia services.

    Anesthesia Services

    CPT-4 Code Definition

    36555 Insertion of non-tunneled centrally inserted central

    venous catheter; under 5 years of age

    36556 age 5 years or older

    36568 Insertion of peripherally inserted central venous

    catheter (PICC), without subcutaneous port or pump;

    under 5 years of age

    36569 age 5 years or older

    36580 Replacement, complete, of a non-tunneled centrally

    inserted central venous catheter, without

    subcutaneous port or pump, through same venous

    access

    36584 Replacement, complete, of a peripherally inserted

    central venous catheter (PICC), without subcutaneous

    port or pump, through same venous access 36620 Arterial catheterization or cannulation for sampling,

    monitoring or transfusion (separate procedure);

    percutaneous

    62319 Injection, including catheter placement, continuous

    infusion or intermittent bolus, not including neurolytic

    substances, with or without contrast (for either

    localization or epidurography), of diagnostic or

    therapeutic substance(s) including anesthetic,

    antispasmodic, opioid, steroid, other solution),

    epidural or subarachnoid; lumbar, sacral (caudal)

    Note: Reimbursable only if the Remarks

    area/Reserved For Local Use field (Box 19) of

    the claim, or a claim attachment, includes a

    statement that the epidural line was not used

    during the surgical procedure, but placed for

    post-operative management.

    93503 Insertion and placement of flow directed catheter (for

    example, Swan-Ganz) for monitoring purposes

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Anesthesiologist CPT-4 procedure codes indicating consultation (99241 99275) or

    Present but not detention time (99360) may be used, depending on the service Administering actually rendered. For example, an anesthesiologist might be Anesthesia required to attend a computed tomography (CT) scan on a child in the

     event that anesthesia may be necessary.

     If anesthesia is not needed, and therefore the anesthesiologist cannot

    bill for any other service during this time, detention time may be

    properly billed. The reason for detention or the nature of the

    consultation must be entered in the Remarks area/Reserved for Local

    Use field (Box 19) of the claim or on an attachment.

    General Anesthesia Services General anesthesia services for procedures not ordinarily requiring Guidelines: Medical anesthesia, or usually requiring only local infiltration, digital block or Necessity topical anesthesia, may be billed if medically necessary using the

    appropriate anesthesia modifiers.

Medical, Radiological, Documentation of the medical necessity is required in the

    Surgical and Pathological Remarks area/Reserved for Local Use field (Box 19) of the claim.

    Procedures

    Pelvic Examination Pelvic examination under anesthesia is by definition an independent Under Anesthesia procedure. However, when it is carried out as an integral part of a

    total service, it does not warrant a separate charge.

     Therefore, a pelvic examination under anesthesia performed in

    conjunction with an induced abortion is not separately reimbursable

    under any circumstances. All claims submitted for a pelvic

    examination performed under anesthesia in combination with an

    induced abortion for the same patient on the same date of service will

    be denied.

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