1 Billing & Compliance for Anesthesia Services Charles Whitten, MD Professor and Chairman
2 Anesthesia Billing Anesthesia is a Unique Specialty ASA* vs. CPT codes Anesthesia Specific Modifiers Time based Billing *ASA = American Society of Anesthesiologists
3 Overview Components of Anesthesia Billing Documentation Requirements Operational Challenges in Meeting Documentation Requirements
4 Formula for Anesthesia Services Billing & Reimbursement (Base Units + Time Units*) X Conversion Factor = Billed Amount or Reimbursement Amount *Time Units = Duration of case in minutes / 15 minutes
5 Billing with Anesthesia Time Base units are determined by the procedure code. (May vary per carrier). Time units are calculated in 15 minute increments for Government carriers (may be negotiated differently for managed care contracts). Conversion Factor is a dollar amount determined by the anesthesia group to bill and by the carrier/carrier contract to determine reimbursement.
6 Specific Modifiers for Anesthesia Services Billed amount or reimbursement is adjusted by modifiers specific to the specialty and according to the following concurrency types: Personally Performed (AA modifier) Concurrent Medical Direction (QY, QK, modifiers) Medical Supervision (AD modifier)
7 Medical Direction Vs. Medical Supervision Medical Direction is up to four concurrent anesthesia procedures. Medical Supervision is more than four concurrent anesthesia procedures.
8 No Concurrency (Personally Performed) Anesthesiologist personally provides anesthesia services to single patient Continuously present No hands-on care to other patients This staffing model is used at CMC
9 Concurrent Medical Direction Anesthesia Team Care Model Up to four CRNAs 1:1-1:4 Two residents (per ABA guidelines) 1:2 One resident/one CRNA (per ABA guidelines) 1:2 Two SRNAs 1:2 If one time unit overlaps and ratio exceeds 1:4 - none of the cases are billable as medical direction This staffing model is used at University Hospital Zale, St. Paul, and the VA
10 Medicare Rules of Medical Direction To meet the requirements of medical direction of residents/fellows/ CRNAs, the staff anesthesiologist must follow and document these 7 steps: 1. Perform the pre-anesthetic exam and evaluation; 2. Prescribes the anesthetic plan; 3. Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence; 4. Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; 5. Monitors the course of anesthesia at frequent intervals; 6. Remain physically present and available for immediate diagnosis and treatment of emergencies; and 7. Provide indicated post-anesthesia care.
11 Medical Supervision No requirement to personally perform most demanding portions of the case. Five to seven CRNAs 1:5 1:7 Maximum reimbursement to MD is 3 base units. No time units are reimbursable. One additional unit may be reimbursable if documentation supports the presence of the MD during induction. No requirement for involvement in post anesthesia care.
12 Other Anesthesia Services Receives patients entering the operating suite for next surgery Checks on or discharges patients from recovery room Coordinates scheduling matters
13 System of Checks and Balances Reconcile anesthesia records with anesthesia logs and operating room schedules Batch anesthesia record with operating room worksheet Confirm seven steps of medical direction Physician Returns Daily/Monthly/Quarterly Internal Audit Annual external audit
14 The Billing Office s Role in Compliance Reconcile the Medical Records with OR log Check the documentation for the seven steps of medical direction Return incomplete records to physician Perform quarterly Audits Provide Education for the Physician Work with the Institutional Compliance Office
15 Potential Documentation Compliance Issues Start time Stop time Discontinuous time Invasive monitors Medical necessity Medical direction Medical Supervision Concurrence Key portions Monitoring course of anesthesia Transfer of care
16 Documenting the Anesthesia Record If it isn t documented it did not happen.
17 Anesthesia Record We currently use paper records at University Hospitals. Our practice at CMC implemented electronic intraoperative anesthesia record in EPIC this past October.
18 Documenting the Anesthesia Record Patient Name Place of Service, inpatient, outpatient etc.. Date of Service, date anesthesia was initiated Name of Surgeon Anesthesia Start and Stop time Type of Anesthesia, general, MAC, spinal, epidural etc
19 Anesthesia Time Starts when the anesthesiologist begins to prepare the patient for anesthesia. Ends when the patient s care is turned over to another type of provider for post surgical care. Anesthesia time should not be rounded. Always use the same time piece when determining start and stop time.
20 Documenting the Anesthesia Record (Cont d). Procedure, surgical procedure performed Diagnosis, reason for the surgery, justification for the physical status modifier or MAC Physical status modifier, P3, P4, P5 Qualifying Circumstances, extreme age, emergency conditions,controlled hypotension or hypothermia.
21 Documenting the Anesthesia Record (Cont d) Invasive Line Placements, CVP, Arterial Line, PA Catheter Date of Injury (Workers Comp) Medically Directing/Supervising Anesthesia Providers Statement, to include the Anes. Plan Presence for induction, emergence, treatment of emergencies, availability and presence.
22 Documenting the Anesthesia Record (Cont d). Anesthesia MD/CRNA/Resident Signature (4). Pre Anesthesia Summary, to include the pre anesthesia examination and evaluation and the Medically Directing/Supervising Anesthesia providers statement of participation and signature. (1) Post Anesthesia Care, statement indicating the status of patient and signature of Medically Directing/Supervising Anesthesia MD (7)
23 OB Anesthesia OB EPIDURALS POST-ANESTHESIA TIME If the faculty is only present for insertion of the labor epidural, then post anesthesia evaluation time should be the ending time of the insertion, when faculty deem the anesthetic successful and the patient to be comfortable. If the case goes from LEA to an operative session (for example: C/S, BTL, forceps, D&C) the postanesthesia time would be end of the operative session. Different faculty may perform the follow-up after the epidural is removed by a resident, RRNA, CRNA and/or nurse. Faculty evaluations after the epidurals are removed must be documented in the progress notes. NOTE: For OPERATIVE CASES: The postanesthesia evaluation date/time should not be earlier than the anesthesia end time documented on page one of the anesthesia epidural record and the operative record. For LABOR EPIDURALS: The postanesthesia evaluation date/time may be earlier than the anesthesia end time.
24 Documenting the Anesthesia Record (Cont d). Statement indicating time of change in the Anesthesia MD,CRNA or Resident, for anesthesia group practices.
25 Operational Challenges to Documentation Completion
26 Anesthesia Coding We manually code from the following documentation sources: the intra-operative anesthesia records, surgeons op reports, Pre and Post Anesthesia records, and discharge summaries (to confirm diagnosis & special circumstances) All of our coders are certified by the American Academy of Professional Coders (CPC certification)
27 Anesthesia Coding Selecting a Procedure Code CPT vs. ASA code Multiple procedures use code with highest base Add on codes If possible use operative report Selecting a Diagnosis Code Choose to the highest specificity (fourth and/or fifth digit). Diagnosis needed to support medical necessity for anesthesia as well as procedure.
28 Monitored Anesthesia Care (MAC) Should include: Pre operative visit, intra operative care and post operative management. During procedure, anesthesia care team is present and provides a variety of services: Monitoring of vital signs, maintaining patient s airway and evaluation of vital functions. Diagnosis and treatment of problems which may occur Administration of sedatives, analgesics, etc as necessary. Other medical services as needed.
29 Monitored Anesthesia Care (MAC) (Cont d) Patient remains able to protect the airway for the majority of the procedure. Medical Necessity (Medicare LMRP) Reimbursement should be same as general anesthesia. Additional Modifier may be required.
30 Modifiers Anesthesia Care Team AA Anesthesia services performed personally by anesthesiologist QY Anesthesiologist medically directs one CRNA QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals AD Medical supervision by a physician: more than four concurrent anesthesia procedures. QX CRNA service: with medical direction by a physician QZ CRNA service: without medical direction by a physician
31 Commonly Used Modifiers (Cont d) Qualifying Circumstances (Add on codes) Anesthesia for patient of extreme age, under 1 year and over Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypotension Anesthesia complicated by emergency conditions(specify).
32 Commonly Used Modifiers (Cont d) -QS Monitored anesthesia care service -G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure -G9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition -GC This service has been performed in part by a resident under the direction of a teaching physician.
33 Resources AMA -CPT ICD-9-CM ASA-Relative Value Guide ASA-Crosswalk Local Medicare and Medicaid Web Sites Anesthesia specialty publications Internet
What You Need to Know About Anesthesia Filing Guidelines 2015 Edition Published by Provider Relations and Education Your Partners in Outstanding Quality, Satisfaction and Service This document provides
1570 Midway Pl. Menasha, WI 54952 920-720-1300 Procedure 1205- Anesthesia Lines of Business: All Purpose: This guideline describes Network Health s reimbursement of anesthesia services. Procedure: Anesthesia
PROVIDER BILLING GUIDELINES Anesthesia Background Qualified medical professionals administer anesthesia to relieve pain while at the same time monitoring and controlling the patients health and vital bodily
ANESTHESIA BILLING AND REIMBURSEMENT POLICY Payment policies apply to all in-network and out-of-network providers who render services to Neighborhood Health Plan of Rhode Island subscribers covered under
Anesthesia Billing: 101 Presented by: Medi-Corp, Inc www.medi-corp.com Disclaimer Statement The material enclosed is based on information that is in effect at the time of this presentation. This presentation
IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES February 2010 This notice will serve as an update to the November 2008 Anesthesia Billing Guidelines and Reimbursement
Anesthesia Coding and Compliance Presented by: Melanie Lafferty June 2015 Conflict of Interest Disclosure Statement Melanie Lafferty, Vice President of Practice Management Medac, Inc. I have the following
Basics of Anesthesia Reimbursement Tracy Paul Young CRNA, MSNA, MBA,SRS LOUSIANNA Paul Carpenter CRNA, MS, SRS MISSISSIPPI Objectives Identify the difference between Professional Fees and Technical Fees
Anesthesia Services Policy Number ANES08272009RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 08/27/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable
Anesthesia Processing Manual Important Information The following disclaimer is applicable to all telephone inquiries and automated communications systems (i.e., telephone and fax) to Blue Cross and Blue
ANESTHESIA SERVICES Policy NHP reimburses participating providers for the administration of general and regional anesthesia, and supportive services performed in conjunction with covered obstetrical, surgical,
Reimbursement Policy Subject: Professional Anesthesia Services Effective Date: 01/01/15 Committee Approval Obtained: 01/01/15 Section: Anesthesia ***** The most current version of our reimbursement policies
Anesthesia Payment & Billing Information Time and Points Eligible Anesthesia Procedures Defined HMO Blue Texas SM and Blue Cross and Blue Shield of Texas have determined that certain anesthesia procedures
Anesthesiology Billing How to Ensure Proper Reimbursement and Avoid a RAC Audit Table of Contents Introduction: The Aggressive RAC Audit... 2 Common Audit Problems How to Prevent an Audit: Key Points to
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Anesthesia Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 1 9 P U B L I S H E D : F E B R U A R Y 25, 2 0 1 6 P O L
Anesthesia Policy Policy Number 2015R0032D Annual Approval Date 3/11/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission
Policy Number 2016R0032B Anesthesia Policy Annual Approval Date 3/11/2015 Approved By REIMBURSEMENT POLICY CMS-1500 Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden
Department of Anesthesiology (Jax) College of Medicine Jacksonville Anesthesiology Billing Compliance Plan Revised October 1, 2015 I. Billing Compliance Administrative Policies and Procedures 1.0 INTRODUCTION
Anesthesia Module Anesthesia Billing Anesthesia billing is unique for the following reasons: CPT to ASA mapping Unit Calculation Fee/Expected Fee Calculation Resident Billing CRNA Billing Concurrency Concurrency
EqualityCareNews October 2006 Coverage ATTENTION PROVIDERS Anesthesia Services Effective 12/1/06 CMS-1500 Bulletin 06-009 EqualityCare covers anesthesia only when administered by a licensed anesthesiologist
INTEGRATING ANESTHESIOLOGIST ASSISTANTS INTO YOUR PRACTICE: WHAT YOU NEED TO KNOW Jay Mesrobian, M.D. John Stephenson, M.D. David Biel, AA C Michael Nichols, AA C I Introduction Incorporation of Anesthesiologist
Anesthesia Coding and Compliance Presented by: Melanie Lafferty July 2014 Introduction The target for this training is to provide you with a basic understanding of anesthesia coding and compliance in regards
Oregon CO-OP Modifier Table - December 2013 Modifier Modifier Description Pricing Functionality 22 Increased Procedural Services Modifier 22 should only be reported with procedure codes that have a global
Private Property of Florida Blue. This payment policy is Copyright 2012, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission
MAKING DOLLAR$ AND $ENSE FROM A CARDIAC ANESTHESIA PRACTICE Christopher A. Troianos, MD Professor and Chair of Anesthesiology Western Pennsylvania Hospital West Penn Allegheny Health System Western Campus
Private Property of Florida Blue. This payment policy is Copyright 2012, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission
50 SHADES OF GREY: OIG AUDITS OF ACADEMIC ANESTHESIA DEPARTMENTS Stanley W. Stead, M.D., M.B.A. President, Stead Health Group, Inc. Section Chair, ASA Section on Professional Practice AMA Relative Value
BILLING COMPLIANCE PLAN: DOCUMENTATION AND VERIFICATION OF THE ANESTHETIC CARE FOURTH ADDITION DEPARTMENT OF ANESTHESIOLOGY UNIVERSITY OF TEXAS MEDICAL BRANCH GALVESTON, TEXAS REVISED APRIL 2009 1 of 22
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850 Center for Medicaid and State Operations/Survey
Suzanne Honor-Vangerov, Esq. CPC, CPC-I 1 Managing Attorney, Lien Unit Floyd Skeren & Kelly LLP Owner of Honor System Consulting Prior Manager of the Division of Workers Compensation Medical Unit, in charge
FACULTY PRACTICE PLAN TEACHING PHYSICIAN BILLING POLICY (Based on Medicare Carriers Manual Transmittal 1780, Section 15016, Supervising Physicians in Teaching Settings, Effective 11/22/2002) PURPOSE The
Step 1: Find the Charge Classes by Zip Code http://www.portal.state.pa.us/portal/server.pt/community/charge_classes_by_zip_co de/10428 The Pennsylvania Workers' Compensation Fee Schedule for Part B providers
PROVIDER BILLING GUIDELINES Modifiers Modifiers are two digit or alphanumeric characters that are appended to CPT and HCPCS codes. The modifier allows the provider to indicate that a procedure was affected
Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 MODIFIERS Policy s are used to increase accuracy in recording patient encounters and compensation. A modifier provides the means
POLICY.........PG0011 EFFECTIVE......10/30/05 LAST REVIEW... 10/13/15 MEDICAL POLICY Modifier Guidelines GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated
The Medical Clean Claims Task force has developed this modifier grid to identify modifiers that are considered to be important in the overall adjudication of a claim from a commercial payer perspective.
Table of Contents Forward... 1 Introduction... 2 Evaluation and Management Services... 3 Psychiatric Services... 6 Diagnostic Surgery and Surgery... 6 Other Complex or High Risk Procedures... 7 Radiology,
Policy Coding and Guidelines EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 09 02 2015 OVERVIEW This Policy provides an overview of coding and guidelines as they pertain to claims submitted to Blue Cross
Application for Educational Membership Personal Information (Please print or type) Name: (Full Legal Name) Date: Date of Birth: Gender: Male Female Address: Suite No: City: State: ZIP: * E-mail: Do Not
University of Kentucky / UK HealthCare Policy and Procedure Policy # A06-030 Title/Description: Documentation and Billing for Professional Services Rendered by Teaching Physicians Purpose: To comply with
PARTNESHIP HEALTHPLAN OF CALIFORNIA HEALTHY KIDS CLAIMS DEPARTMENT VII.A. Anesthesia Billing To bill for anesthesia services, use the five-digit CPT-4 anesthesia code applicable to the procedure with the
Subject: Modifier Rules NY Policy: 0017 Effective: 02/01/2014 06/30/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
Compliance Department SURGERY AND SURGICAL MODIFIERS 11/2010 Surgical Care Presence Requirements In order to bill for surgical services, teaching physician must be present during all critical and key portions
R Medicare Information for Advanced Practice Nurses and Physician Assistants September 2010 / ICN: 901623 This publication provides information about required qualifications, coverage criteria, billing,
MEDICAL SERVICE RESEARCH AND DEVELOPMENT PLAN AND UT PHYSICIANS BILLING AND DOCUMENTATION GUIDELINES MEDICAL SERVICE RESEARCH AND DEVELOPMENT PLAN AND UT PHYSICIANS BILLING AND DOCUMENTATION GUIDELINES
WORKERS' COMPENSATION MEDICAL FEE SCHEDULE RULE 40.000 40.000 Workers' Compensation Medical Fee Schedule The five-digit numeric codes and descriptions included in Rule 40.000, Medical Fee Schedule, are
CAUTION: Read the ICD-9 Policy Holding Library page about policy in this document. anest ub Anesthesia Billing Examples: UB-04 1 Examples in this section are to help providers bill for anesthesia services
MEDICARE CLAIMS PROCESSING MANUAL Accessed September 25, 2005 100.1 - Payment for Physician Services in Teaching Settings Under the MPFS Payment is made for physician services furnished in teaching settings
Health Law Alert March 31, 2006 About Hall Render Hall, Render, Killian, Heath & Lyman is a full service health law firm with offices in Indiana, Kentucky, Michigan and Wisconsin. Since the firm was founded
The Fraud and Abuse Environment for Anesthesiologists Jointly Sponsored By: Anesthesia Business Consultants, LLC Tulane University School of Medicine Department of Anesthesiology The Center for Continuing
There are eight components to the charge process for surgical services: 1. Pre op prep and care 2. Anesthesia 3. Operating room time charges 4. Equipment charges 5. Recovery / Post Anesthesia Care Unit
Preface Summary of Changes Table of Contents Service Contacts November 2014 Replaces: September 2014 S-5787 11/14 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers
Payment Policies Appendices Appendix E: Modifiers that affect payment Note: Only modifiers that affect payment are listed in this Appendix. Refer to current CPT and HCPCS books for a complete list of modifiers,
WellCare and Harmony Health Plan s claim payment policies are based on publicly distributed guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), the
CAUTION: Read the ICD-9 Policy Holding Library page about policy in this document. anest cms Anesthesia Billing Examples: CMS-1500 1 Examples in this section are to assist providers in billing for Anesthesia
The Impact of Regional Anesthesia on Perioperative Outcomes By Dr. David Nelson As a private practice anesthesiologist, I am often asked: What are the potential benefits of regional anesthesia (RA)? My
The Scope of Practice of Nurse Anesthetists American Society of Anesthesiologists January 2004 Table of Contents Preface.................................................................................
CODE AUDITING RULES As part of Coventry Health Care of Missouri, Inc s commitment to improve business processes, we are implemented a new payment policy program that applies to claims processed on August
Table of Contents ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES For treatment before 2/1/09 Introduction and Purpose Reference Materials Section 1. Ambulatory
Good morning, Mr. Chairman and distinguished members of the House Professional Licensure Committee. My name is Dr. Erin Sullivan. I am president of the Pennsylvania Society of Anesthesiologists and a board
SECTION 5 HOSPITAL SERVICES Table of Contents 1 GENERAL POLICY... 2 1-1 Clients Enrolled in a Managed Care Plan... 3 1-2 Clients NOT Enrolled in a Managed Care Plan (Fee-for-Service Clients)..................
How Do I Ask Questions During this Training? Questions that arise during the training may be emailed to: firstname.lastname@example.org. 2 Training Objectives Describe new information contained in
Modifier Magic April 15, 2015 MMBA Modifiers Modifiers should be reported to bypass a clinical edit ONLY if the criteria for the use for the modifiers is met and supporting documentation is included in
Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule a) In accordance with Sections 8(a), 8.2 and 16 of the Workers' Compensation Act [820 ILCS 305/8(a), 8.2 and 16] (the Act),
Scope and Standards for Nurse Anesthesia Practice Copyright 2013 222 South Prospect Ave. Park Ridge, IL 60068 www.aana.com Scope and Standards for Nurse Anesthesia Practice The AANA Scope and Standards
HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND CONSULTING WITH REAL-WORLD PERSPECTIVE. Update of Cost Effectiveness of Anesthesia Providers Final Report Prepared for: American Association of Nurse
Anatomical modifiers Anesthesia modifiers EA, EB and EC FB, FC and FD Anatomical modifiers are used to indicate that a procedure or service was performed at a specific anatomic site or to indicate that
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Global Surgery Fact Sheet Fact Sheet Definition of a Global Surgical Package Medicare established a national definition
Payment Policy Mid-Level Practitioner EFFECTIVE DATE: 02 02 2006 POLICY LAST UPDATED: 10 01 2013 OVERVIEW This policy documents the services covered when rendered by a BCBSRI credentialed Mid-level practitioners