Transcript 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
Let’swill
start by discussing
about
Then, learn
you will
learn
general
anesthesia
anesthesia services,
how anesthesia services
how they
arehow
guidelines
and
are
used
for
pain
reimbursed,
and
the
anesthesia
services
are
management
services.
circumstances
that can
reimbursed...
affect reimbursement.
Part I: Anesthesia
 Anesthesia Guidelines
 Reimbursement of Anesthesia Services
 Modifiers:
 Basic Modifiers
 Physical Status Modifiers
 Qualifying Circumstances
CA Regulations Training - Anesthesia
What is Anesthesiology?

Anesthesiology is the branch of medicine concerned with the
control of acute or chronic pain.
Anesthesia includes
the use of:






Sedative drugs
Analgesic drugs
Hypnotic drugs
Anti-emetic drugs
Respiratory drugs
Cardiovascular drugs
CA Regulations Training - Anesthesia
Anesthesia also
involves:



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Preoperative assessment
Intra-operative patient
management
Postoperative care
Autonomic, neuromuscular,
cardiac, and respiratory
physiology
Anesthesia Guidelines

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.
CA Regulations Training - Anesthesia
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.
Anesthesia Services

Anesthesiologists may bill for a variety of services and methods of
anesthesia.
Anesthesia Methods:
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General anesthesia
Moderate sedation
Regional anesthetic
CA Regulations Training - Anesthesia
Anesthesia services include:

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Pre-operative visit with the patient.
Ordering and giving medication.
Monitoring the patient’s vital signs and
level of sedation.
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:
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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.
CA Regulations Training - Anesthesia

The system is
automated to deny all
non-invasive monitoring
services billed with an
anesthesia code.
Separately Reimbursable
Procedures
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In contrast, anesthesiologists can bill for invasive procedures.
Some of these invasive
procedures include:
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CA Regulations Training - Anesthesia
Insertion of a central venous
catheter
Esophageal catheter
Swan-Ganz catheter
Anesthesia Reimbursement

Anesthesiologists are reimbursed per a base unit value
assigned to each anesthesia code and by units of time.
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.
CA Regulations Training - Anesthesia

Calculations are automated
but may be required in a
manual pricing situation.
Anesthesia Reimbursement
CPT 00630: Anesthesia for lumbar spine surgery
Duration: 5 hours, 35 minutes
Base Units: 8
TIME UNITS:
First 4 hours:
TIME UNITS:
Remaining 1 hr, 35 minutes:
= 16 units
335 – 240 = 95 minutes
95 minutes/10 minutes per unit
= 9 units + 5 extra minutes
What happens to
4 hours = 240 minutes
the extra 5
minutes?
240 minutes/15 minutes
per unit
Base Units + Time Units = Total Units
8 + 16 + ? = ?
CA Regulations Training - Anesthesia
Anesthesia Reimbursement
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!
TIME UNITS:
Remaining time:
335 – 240 = 95 minutes
95 minutes/10 minutes per unit
= 10
9 +units
5 extra minutes
Base Units + Time Units = Total Units
8 + 16 + 10 = 34
CA Regulations Training - Anesthesia
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
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!
Base Units + Time Units = Total Units
4+4=8
CA Regulations Training - Anesthesia
Modifiers
Now that you are
familiar with the basics
will begin let’s
by
ofWe
anesthesia,
discuss how
modifiers
discussing
a few
basic
and extreme
anesthesia
modifiers...
circumstances can alter
reimbursement.
Part I: Anesthesia
 Anesthesia Guidelines
 Reimbursement of Anesthesia Services
 Modifiers:
 Basic Modifiers
 Physical Status Modifiers
 Qualifying Circumstances
CA Regulations Training - Anesthesia
Modifiers

As you know, each section of the OMFS has a list of modifiers
that pertain to those services.
We will discuss the following
modifiers:
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Recall that modifiers
indicate that a procedure
was altered by additional
circumstances, but was not
changed from its standard
definition.
CA Regulations Training - Anesthesia


Modifier 36
Modifier 47
Modifier 48
See the OMFS for a complete list of
modifiers!
Modifier 36
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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:
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Require endotracheal
intubation for prone or other
difficult positions
Require surgical field
avoidance
Are performed for medical
necessity
...may warrant an additional
charge.
CA Regulations Training - Anesthesia
36
Anesthesia Procedures:
This modifier increases the
basic value for these
procedures to four base units.
Other applicable modifiers also
apply.
Modifier 47

In some instances, anesthesia is provided by a
surgeon, rather than an anesthesiologist.
47 Anesthesia 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.
CA Regulations Training - Anesthesia
Certified Registered
Nurse Anesthetists

Certified Registered Nurse Anesthetists (CRNA) also administer
anesthesia, although they must be under the supervision of an
anesthesiologist.
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Both the
anesthesiologist and the
CRNA are reimbursed.
The anesthesiologist is paid for
the base units and a reduced
number of time units.
The CRNA is paid the
remainder of the total
reimbursement of an
anesthesiologist performing
the service.
CA Regulations Training - Anesthesia

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.
Lastly, the anesthesiologist must be
involved in the medical direction of the
patient, including pre and post-operative
care.
Modifier 48

Modifier 48 indicates that a CRNA performed anesthesia services.
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.
CA Regulations Training - Anesthesia
Certified Registered
Nurse Anesthetists

Suppose Dr. Jones supervises two operating rooms with CRNAs
giving anesthesia in each. He does not administer the anesthesia
himself.
Operating Room 1
CA Regulations Training - Anesthesia
Dr. Jones
Operating Room 2
Certified Registered
Nurse Anesthetists
Operating Room 1
Operating Room 2
Dr. Jones
Duration:
1 hour, 15 minutes
Base Value = 4
CA Regulations Training - Anesthesia
Duration:
45 minutes
Base Value = 6
Certified Registered
Nurse Anesthetists
Operating Room 1
Operating Room 2
Duration: 1 hour, 15 minutes
Base Value = 4
75 minutes = 5 units
Total Units = 9
Anesthesiologist: 1 unit/hour
(or fraction thereof) = 2 time units
Duration: 45 minutes
Base Value = 6
45 minutes = 3 units
Total Units
=9
Now
you try...
Anesthesiologist Total = 2 + 4 = 6
CRNA: 9 – 6 = 3 Units
CA Regulations Training - Anesthesia
Anesthesiologist:
1 time
unit
How many
units can be
reimbursed
to
the anesthesiologist and the CRNA?
Anesthesiologist Total = 1 + 6 = 7
CRNA: 9 – 7 = 2 Units
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.
CA Regulations Training - Anesthesia
Physical Status Modifiers
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Anesthesia complicated by the patient’s condition may be additionally
reimbursed if documentation supports the presence of significant
disease.
While hypertension and diabetes are
These significant complications not considered significant enough to
are indicated by physical
warrant use of the higher level physical
status modifiers.
status modifiers, conditions such as:
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Congestive heart failure
Emphysema
Uncontrolled epilepsy
...are reimbursable.
CA Regulations Training - Anesthesia
Physical Status Modifiers

The physical status modifiers and their values are:
Modifier
Description
Unit
P1
normal, healthy patient
0
P2
patient with mild systemic disease
0
P3
patient with severe systemic disease
1
P4
patient with severe systemic disease that is a constant threat to life
2
P5
moribund patient not expected to live without the surgery
3
P6
brain dead patient for harvesting
0
CA Regulations Training - Anesthesia
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
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!
Base Units + Time Units + P3 Modifier Units= Total Units
7 + 14 + 1 = 22
CA Regulations Training - Anesthesia
Physical Status Modifiers

Some providers will attach a
physical status modifier to all
anesthesia services, while
others will only attach those
with unit values greater than
zero.
Either method is acceptable and
the system is automated to pay
the modifier.
It is the
processor’s
responsibility to
verify that
documentation
justifies the
addition of the
payable modifiers.
CA Regulations Training - Anesthesia
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.
CA Regulations Training - Anesthesia
Qualifying Circumstances

You have probably realized that there are certain circumstances which
make giving anesthesia much more difficult.
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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.

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.
CA Regulations Training - Anesthesia
Qualifying Circumstances

Qualifying circumstances are indicated by special codes, not modifiers.
Qualifying Circumstance codes include:
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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).
CA Regulations Training - Anesthesia
Qualifying Circumstances
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It is critical that documentation support the addition of qualifying
circumstances.
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The age of a patient is easily
verified to confirm an instance
of “extreme age.”
CA Regulations Training - Anesthesia
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.
Qualifying Circumstances

You probably realize that like other providers, anesthesiologists can
incorrectly bill for certain codes.
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.
CA Regulations Training - Anesthesia
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.
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
CA Regulations Training - Anesthesia
Pain Management Services

Pain management occurs in two distinct circumstances:
Post-operative Pain Control
CA Regulations Training - Anesthesia
Chronic Pain Control
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.
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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.
CA Regulations Training - Anesthesia
Post-operative Pain Control
Post-operative Pain Control
CA Regulations Training - Anesthesia
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.
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.
CA Regulations Training - Anesthesia
The catheter insertion is separately
reimbursed 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.
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.

CA Regulations Training - Anesthesia
In this case, it is part of the
global surgery package.
Chronic Pain Control

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.
However, the most common
treatment is injection.
Chronic Pain Control
CA Regulations Training - Anesthesia
Chronic Pain Control
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.

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.
CA Regulations Training - Anesthesia
Chronic Pain Control

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.
Often, anesthesiologists will
mistakenly indicate the
anesthesia base value in the
units field on the bill.
CA Regulations Training - Anesthesia
Remember, the bill review
system already calculates the
base value associated with a
procedure.
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:

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

performed multiple injections
billed for time units
indicated the anesthesia base value of the
service in the unit field
Unfortunately, all the above scenarios are viable possibilities.
CA Regulations Training - Anesthesia
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.
CA Regulations Training - Anesthesia
Chronic Pain Control
3 Joint Injections:
left hip, right hip, & right knee
3 Injections
The lines are separated, and the
procedures are reimbursed at
multiple procedure cascade.
Left hip: 20610 x 100% of FS value
Right hip: 20610 x 50% of FS value
Right knee: 20610 x 25% of FS value
CA Regulations Training - Anesthesia
Chronic Pain Control
Single large joint injection
representing time units or ASA
base value
3 Time Units
The processor will need to
change the unit field to 1 and the
TOS to 2 to represent the actual
service performed.
1 injection
Billed: 20610, TOS 7, Units: 3
Paid: 20610 x 100% of FS value TOS
2, Units: 1
CA Regulations Training - Anesthesia
Chronic Pain Control

If multiple types of injections are performed, they are reimbursed at
multiple procedure cascade.
Example:
62278 lumbar epidural:
100% FS
64440 injection paravertebral nerve:
50% FS
20550 trigger point injection:
25% FS
CA Regulations Training - Anesthesia

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.
Pain Management Services

A common error in pain management occurs when providers bill for an E
& M service each time the patient comes in for an injection.
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.
CA Regulations Training - Anesthesia
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.
Summary
Anesthesia: Services
and Procedures
How to calculate
anesthesia
reimbursements.
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.
CA Regulations Training - Anesthesia
Module Quiz
It’s time to check your knowledge of the concepts presented in this module.

This quiz is scored.

You must achieve a score of 80% to pass. You may attempt this quiz as
many times as needed to achieve a passing score.

When finished, you may move on to the next module.
CA Regulations Training - Anesthesia
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