Concurrent Medically Directed Procedures
Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether the other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and one Medicare patient, this represents three (3) concurrent cases.
The following example illustrates this concept and guides physicians in determining how many procedures are directed:
Procedures A through E are medically directed procedures involving CRNAs. The starting and ending times for each procedure represent the periods during which anesthesia times are counted.
Procedure A begins at 8:00AM and ends at 8:20AM
Procedure B begins at 8:10AM and ends at 8:45AM
Procedure C begins at 8:30AM and ends at 9:15AM
Procedure D begins at 9:00AM and ends at 12:00 noon
Procedure E begins at 9:10AM and ends at 9:55AM
Procedure Number of Concurrent Medically Directed Procedures Base Unit Reduction Percentage
A 2 10%
B 2 10%
C 3 25%
D 3 25%
E 3 25%
A physician who is concurrently directing the administration of anesthesia to not more than four (4) surgical patients cannot ordinarily be involved in rendering additional services to other patients.
However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.
However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. No fee schedule payment is made.
The examples listed above are not intended to be an exclusive list of allowed situations. It is expected that the medically-directing anesthesiologist is aware of the nature and type of services he or she is medically directing, and is personally responsible for determining whether his supervisory capacity would be diminished if he or she became involved in the performance of a procedure. It is the responsibility of this medically-directing anesthesiologist to provide services consistent with these regulations.
Friday 29 April 2011
Thursday 28 April 2011
payment rules for anesthesia billing
Payment Rules
The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor. The following formulas are used to determine payment:
• Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Participating Conversion Factor = Allowance
• Non-Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Non-Participating Conversion Factor=Allowance
• Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%
• Non-Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%
• Non-Medically Directed CRNA (Modifier QZ)
(Base Units + Time Units) x Participating Conversion Factor = Allowance
• CRNA Medically Directed (Modifier QX)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%
The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor. The following formulas are used to determine payment:
• Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Participating Conversion Factor = Allowance
• Non-Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Non-Participating Conversion Factor=Allowance
• Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%
• Non-Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%
• Non-Medically Directed CRNA (Modifier QZ)
(Base Units + Time Units) x Participating Conversion Factor = Allowance
• CRNA Medically Directed (Modifier QX)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%
Tuesday 26 April 2011
PAYMENT AND REIMBURSEMENT for anesthesia billing
PAYMENT AND REIMBURSEMENT
Payment at Personally Performed Rate
The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.
Payment at Medically Directed Rate
When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.
These services are to be billed as follows:
1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.
Payment at Non-Medically Directed Rate
In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.
These services are to be billed as follows:
1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.
Payment at Medically Supervised Rate
Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.
Payment at Personally Performed Rate
The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.
Payment at Medically Directed Rate
When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.
These services are to be billed as follows:
1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.
Payment at Non-Medically Directed Rate
In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.
These services are to be billed as follows:
1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.
Payment at Medically Supervised Rate
Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.
Monday 25 April 2011
Teaching Anesthesiologist service - GC modifier
Anesthesia Services and Teaching Anesthesiologist
If a teaching anesthesiologist is involved in a single procedure with one resident, the anesthesia services will be paid at the personally performed rate. The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure.
The teaching physician’s physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, the anesthesiologist’s services will be paid at the medically directed rate.
Use modifier GC (Teaching Physician Service) to indicate the service has been performed in part by a resident under the direction of a teaching physician. This modifier is added after the anesthesia modifier.
Non-Covered Anesthesia Services
The following anesthesia services are non-covered:
• Stand By
If a teaching anesthesiologist is involved in a single procedure with one resident, the anesthesia services will be paid at the personally performed rate. The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure.
The teaching physician’s physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, the anesthesiologist’s services will be paid at the medically directed rate.
Use modifier GC (Teaching Physician Service) to indicate the service has been performed in part by a resident under the direction of a teaching physician. This modifier is added after the anesthesia modifier.
Non-Covered Anesthesia Services
The following anesthesia services are non-covered:
• Stand By
Friday 22 April 2011
anesthesia billing - some specific points
Some specific points that you should be aware of Anesthesia:
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. NHIC 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.)
In the unusual event that a second physician (other than the one performing the diagnostic or therapeutic services) provides moderate sedation in the facility setting for the procedures listed in CPT Appendix G, the second physician can bill 99148 to 99150, but cannot report these codes when the second physician performs these services (on the same day as a medical/surgical service) in the non-facility setting.
If an anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections, and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991. In this case, the service must meet the criteria for monitored anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.
There is no CPT code for the performance of local anesthesia, and as such, payment for this service is considered to be part of the payment for the underlying medical or surgical service. Therefore, if the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation (such as a local or topical anesthesia), then the conscious sedation code should not be reported and the contactor will allow no payment.
When denying claims, as appropriate under this policy, contractors will use the message when the service is bundled into the other service: “Payment is included in another service received on the same day.”
Contractors will adjust claims brought to their attention that were not processed in accordance with the Medicare physician fee schedule data base indicators assigned to the conscious sedation codes. Requests for reopening may be submitted to the Written Inquiries Department in your jurisdiction.
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. NHIC 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.)
In the unusual event that a second physician (other than the one performing the diagnostic or therapeutic services) provides moderate sedation in the facility setting for the procedures listed in CPT Appendix G, the second physician can bill 99148 to 99150, but cannot report these codes when the second physician performs these services (on the same day as a medical/surgical service) in the non-facility setting.
If an anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections, and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991. In this case, the service must meet the criteria for monitored anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.
There is no CPT code for the performance of local anesthesia, and as such, payment for this service is considered to be part of the payment for the underlying medical or surgical service. Therefore, if the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation (such as a local or topical anesthesia), then the conscious sedation code should not be reported and the contactor will allow no payment.
When denying claims, as appropriate under this policy, contractors will use the message when the service is bundled into the other service: “Payment is included in another service received on the same day.”
Contractors will adjust claims brought to their attention that were not processed in accordance with the Medicare physician fee schedule data base indicators assigned to the conscious sedation codes. Requests for reopening may be submitted to the Written Inquiries Department in your jurisdiction.
Monday 18 April 2011
Pain management cpt codes 62310, 62319, 64415 - 64449
Pain Management - Anesthesia
Pain Management Consultation
Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. However, normal postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported.
Postoperative Pain Control Procedures
When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service. Examples of such procedures include:
62310-62319 Epidural or subarchnoid injections
64415-64416 Brachial plexus injection, single or continuous
64445-64448 Sciatic or femoral injections, single or continuous
64449 Lumbar plexus injections, continuous
These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.
NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day.
Daily Management of Continuous Pain Control Techniques
Daily hospital management of continuous epidural or subarachnoid drug administration is reported using CPT code 01996 (1 unit of service daily). This code may be reported on the first and subsequent postoperative days as medically necessary.
When continuous block codes 64416, 64446, 64448, or 64449 are reported on the day of surgery, no additional reporting of daily management is permitted during the following ten days (10 day global period). When these injections procedures constitute the main surgical anesthetic and are therefore not separately reported on the day of surgery, subsequent days’ hospital management is reported using the appropriate hospital visit code (99231-99233).
Pain Management Consultation
Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. However, normal postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported.
Postoperative Pain Control Procedures
When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service. Examples of such procedures include:
62310-62319 Epidural or subarchnoid injections
64415-64416 Brachial plexus injection, single or continuous
64445-64448 Sciatic or femoral injections, single or continuous
64449 Lumbar plexus injections, continuous
These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.
NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day.
Daily Management of Continuous Pain Control Techniques
Daily hospital management of continuous epidural or subarachnoid drug administration is reported using CPT code 01996 (1 unit of service daily). This code may be reported on the first and subsequent postoperative days as medically necessary.
When continuous block codes 64416, 64446, 64448, or 64449 are reported on the day of surgery, no additional reporting of daily management is permitted during the following ten days (10 day global period). When these injections procedures constitute the main surgical anesthetic and are therefore not separately reported on the day of surgery, subsequent days’ hospital management is reported using the appropriate hospital visit code (99231-99233).
Sunday 20 March 2011
CPT codes which are not inclusive in Anesthesia billing
CPT® codes describing services that are integral to an anesthesia service include but are not limited to, the following:
• 99201-99499 (Evaluation and management)
The CPT® book, in its Anesthesia Guidelines, at the start of the Anesthesia section, states, “These services include the usual preoperative and postoperative visits….”
In a copy of a lecture presented by Dr. James Arens, posted on the ASA website, he discusses the fact that these pre-operative visits are not payable.
“For many years the preoperative visit was considered to be part of the global fee for anesthesia services based upon base units plus time. With the advent of preoperative anesthesia(assessment) clinics, the scope of this service has undergone drastic change. The history and past records review has become much more extensive. The evaluation of the patient and the explanation of the risk and options have also become much more detailed. I have heard surgeons state that they are no longer "capable" of assessing patients to undergo anesthesia. Yet the ability to bill for such services is very limited. The values of a well run preoperative clinic are self-evident. However, the inability to collect for these services rendered has caused several clinics to be closed. The codes (99201-99205) for evaluation and management services are quite simple. However, reimbursement for this valuable service remains problematic.”
Summary:
It would be improper for any group to bill for preoperative anesthesia assessments. The payment for that service is included in the payment for the anesthesia payment itself. Any money collected for these services in the would have to be returned to the payers. In addition, any hospital providing this service would need to review with its attorney the issue of providing financial support to a for-profit entity.
• 99201-99499 (Evaluation and management)
The CPT® book, in its Anesthesia Guidelines, at the start of the Anesthesia section, states, “These services include the usual preoperative and postoperative visits….”
In a copy of a lecture presented by Dr. James Arens, posted on the ASA website, he discusses the fact that these pre-operative visits are not payable.
“For many years the preoperative visit was considered to be part of the global fee for anesthesia services based upon base units plus time. With the advent of preoperative anesthesia(assessment) clinics, the scope of this service has undergone drastic change. The history and past records review has become much more extensive. The evaluation of the patient and the explanation of the risk and options have also become much more detailed. I have heard surgeons state that they are no longer "capable" of assessing patients to undergo anesthesia. Yet the ability to bill for such services is very limited. The values of a well run preoperative clinic are self-evident. However, the inability to collect for these services rendered has caused several clinics to be closed. The codes (99201-99205) for evaluation and management services are quite simple. However, reimbursement for this valuable service remains problematic.”
Summary:
It would be improper for any group to bill for preoperative anesthesia assessments. The payment for that service is included in the payment for the anesthesia payment itself. Any money collected for these services in the would have to be returned to the payers. In addition, any hospital providing this service would need to review with its attorney the issue of providing financial support to a for-profit entity.
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