Coding and Payment Guide for Anesthesia Services. An essential coding, billing, and reimbursement resource for anesthesiology and pain management

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1 Coding and Payment Guide for Anesthesia Services An essential coding, billing, and reimbursement resource for anesthesiology and pain management 2011

2 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents and Format of This Guide... 2 How to Use This Guide... 3 The Reimbursement Process...5 Coverage Issues... 5 Payer Types... 5 Payment Methodologies... 9 Calculating Costs Other Factors Influencing Payment Correct Coding Policies for Anesthesia Services Workers Compensation Collection Policies Documentation An Overview...35 Methods of Documentation General Guidelines for Documentation Fraud and Abuse Compliance Action Plan Claims Processing...43 What to Include on Claims Clean Claims The Health Insurance Portability and Accountability Act Processing the Claim The Appeals Process Medicare Benefit Notices The CMS-1500 Claim Form The UB-04 Claim Form...69 Procedure Codes...77 Structure the of Book...77 Coding Conventions...77 Unlisted Procedures...78 Modifiers...78 Payment for Anesthesia Services...79 Payment for Surgical Services and Procedures...80 Global Surgery Packages...80 Bundled Services Anesthesia...81 Index ICD-9-CM Index ICD-9-CM Coding Conventions Coding Neoplasms Manifestation Codes Official ICD-9-CM Guidelines for Coding and Reporting ICD-9-CM Codes Medicare Official Regulatory Information Glossary Appendix A: s Index Ingenix codes only 2010 American Medical Association. All Rights Reserved. iii

3 Introduction HCPCS Level I or Codes The Centers for Medicare and Medicaid Services (CMS), in conjunction with the American Medical Association (AMA), the American Dental Association (ADA), and several other professional groups developed, adopted, and implemented a coding system describing services rendered to patients. Known as HCPCS Level I, the coding system is the most commonly used system to report medical services and procedures. Copyright of codes and descriptions is held by the AMA. This system reports outpatient and provider services. The three categories of codes predominantly describe medical services and procedures, and are adapted to provide a common billing language that providers and payers can use for payment purposes. The codes are widely used and required for billing by both private and public insurance carriers, managed care companies, and workers compensation programs. A requirement of HIPAA is that codes are used for the reporting of physician and other health care services. The AMA s Editorial Panel reviews the coding system and adds, revises, and deletes codes and descriptions. The panel accepts information and feedback from providers about new codes and revisions to existing codes that could better reflect the services or procedures. The majority of codes are found in category I of the coding system. These five-digit numeric codes describe procedures and services that are customarily performed in clinical practices. category II codes are supplemental tracking codes that are primarily used when participating in the Physician Quality Reporting Initiative (PQRI) established by Medicare and are intended to aid in the collection of data about quality of care. At the present time, participation in this program is optional and physicians should not report these codes if they elect not to participate. Category II codes are alphanumeric, consisting of four digits followed by an F and should never be used in lieu of a category I code. This series of codes is updated on a biannual basis (January 1 and July 1), with codes that are released becoming effective six months later (e.g., codes released on January 1 become effective July 1). Refer to the AMA website at for the most recent listing. Category III of the coding system contains temporary tracking codes for new and emerging technologies that are meant to aid in the collection of data on these new services and procedures. Indicated by four numeric digits followed by a "T, like category II codes, category III codes are released twice a year (January 1 and July 1) and can be found on the on the AMA website. RVUs are not assigned for these codes, and payment is made at the discretion of the local payer. Once implemented, a service described by a category III code may eventually become a category I code. HCPCS Level II Codes HCPCS Level II codes are commonly referred to as national codes or by the acronym HCPCS (Healthcare Common Procedure Coding System, pronounced hik-piks). HCPCS codes are used to bill Medicare and Medicaid patients and are also used by some third-party payers. HCPCS Level II codes, periodically updated and published annually by CMS, are intended to supplement the coding system by Coding and Payment Guide for Anesthesia Services including codes for nonphysician services, durable medical equipment (DME), and office supplies. These Level II codes consist of one alphabetic character (A through V) followed by four numbers. Claim Forms Institutional (facility) providers use the UB-04 claim form, also known as the CMS-1450, or the electronic 837i format to file a Medicare Part A claim to Medicare fiscal intermediaries (FI). Noninstitutional providers and suppliers (private practice or other health care providers offices) utilize the CMS-1500 form or the 837p electronic format to submit claims to Medicare contractors for Medicare Part B covered services. Medicare Part A coverage includes inpatient hospital, skilled nursing facilities (SNF), hospice, and home health. Medicare Part B coverage provides payment for medical supplies, physician, and outpatient services. Not all services rendered by a facility are inpatient services. Providers working in facilities routinely render services on an outpatient basis. Outpatient services are provided in settings that include rehabilitation centers, certified outpatient rehabilitation facilities, SNFs, and hospitals. Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or UB-04, depending on the payer. For professional component billing, most claims are filed using ICD-9-CM diagnosis codes to indicate the reason for the service, codes to identify the service provided, and HCPCS Level II codes to report supplies on the CMS-1500 paper claim or the 837p electronic format. Contents and Format of This Guide The first three chapters following this introduction provide information regarding the reimbursement process, documentation, and claim completion, respectively. The fifth chapter, Procedure Codes for Anesthesia Services, contains a numeric listing of procedure codes. Each page identifies the information associated with that procedure including an explanation of the service, coding tips, associated diagnoses, related terms, Centers for Medicare and Medicaid Services (CMS) internet-only manual references that identify any official references found in the online CMS Manual System. The full excerpt from the online CMS Manual System pertaining to the reference is provided in the Medicare official regulatory chapter. The procedure code pages also have a list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive or mutually exclusive and should not be reported separately. Finally, all relative value information relevant to the code is listed at the bottom of the page. Following this chapter you will find a procedure code index, an index of ICD-9-CM diagnosis codes for anesthesia services, and an index of HCPCS Level II codes for anesthesia services. Medicare Official Regulatory Information The full excerpts from the online online CMS Manual System pertaining to anesthesia are provided in this section. Since these excerpts often do not identify the guideline with corresponding or HCPCS Level II codes our experts have crosswalked the appropriate reference, wherever possible, to the applicable 2 codes only 2010 American Medical Association. All Rights Reserved Ingenix

4 Procedure Codes Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level lumbar or sacral, each additional level (List separately in addition to code for primary procedure) cervical or thoracic, single level cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Explanation These procedures are performed to treat chronic pain. The affected nerve is destroyed using chemical, thermal, electrical, or radiofrequency techniques, which may be used independently or in combination. These procedures are designed to destroy the specific site(s) in the nerve root that produce(s) the pain while leaving sensation intact. Generally intravenous conscious sedation is used during the initial phase of the procedure so that the patient can assist the physician in identifying the site of pain and the correct placement of the neurolytic agent, and local anesthesia is administered during the destruction phase of the procedure. Using separately reportable fluoroscopic guidance, a needle is inserted into the affected nerve root. An electrode is inserted through the needle and a mild electrical current is passed through the electrode. The current produces a tingling sensation at a site on the nerve. The electrode is manipulated until the tingling sensation is felt at the same site as the pain. Once the physician has determined that the electrode is positioned at the site responsible for the pain, a local anesthetic is administered and a neurolytic agent applied. Chemical destruction involves injection of a neurolytic substance (e.g., alcohol, phenol, glycerol) into the affected nerve root. Thermal techniques use heat. Electrical techniques use an electrical current. Radiofrequency, also referred to as radiofrequency rhizotomy, uses a solar or microwave current. Report when the site is the intercostal nerve. Report when one or more lumbar/sacral paravertebral facet joint nerve is treated and when the treatment is at the cervical/thoracic facet joint level. Report for the pudendal nerve, for the plantar common digital nerve, and for other peripheral nerves or branches. Coding Tips As add-on codes, and are not subject to multiple procedure rules. No reimbursement reduction or modifier 51 is applied. Add-on codes describe additional intraservice work associated with the primary procedure. They are performed by the same physician on the same date of service as the primary service/procedure, and must never be reported as stand-alone codes. Report in conjunction with Report in conjunction with These are unilateral procedures. If performed bilaterally, some payers require that the service be reported twice with modifier 50 appended to the second code while others require identification of the service only once with modifier 50 appended. Check with individual payers. Modifier 50 identifies a procedure performed identically on the opposite side of the body (mirror image). Fluoroscopic guidance is reported separately, see code ICD-9-CM Diagnostic Codes Lumbosacral plexus lesions Phantom limb (syndrome) Lesion of sciatic nerve Ankylosing spondylitis Spinal enthesopathy Lumbosacral spondylosis without myelopathy Spondylosis with myelopathy, lumbar region Ankylosing vertebral hyperostosis Traumatic spondylopathy Displacement of lumbar intervertebral disc without myelopathy Schmorl's nodes, lumbar region Degeneration of lumbar or lumbosacral intervertebral disc Intervertebral lumbar disc disorder with myelopathy, lumbar region Postlaminectomy syndrome, lumbar region Spinal stenosis of lumbar region, without neurogenic claudication Lumbago Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Unspecified backache IOM References Coding and Payment Guide for Anesthesia Services 100-2,15,260; 100-3,160.1; 100-4,12,30; 100-4,12,90.3; 100-4,14,10 CCI Version , 95822, , , 95900, 95904, 95920, Also not with 64622: 0216T, 0228T, 0230T, 36000, , , 36440, 36600, 36640, 37202, 43752, , 62311, 62319, , , , 64479, 64483, 64493, , 69990, , 77002, , , 93318, 94002, 94200, 94250, , 94770, , 95819, 95829, 95870, , 95955, 96360, 96365, 96372, , , 99150, J2001 Also not with 64623: 0230T, 62311, 64483, , Also not with 64626: 0213T, 0228T, 0230T, 36000, , , 36440, 36600, 36640, 37202, 43752, , 62310, 62318, , , 64479, 64483, 64490, , 69990, , 77002, , , 93318, 94002, 94200, 94250, , 94770, , 95819, 95829, 95870, , 95955, 96360, 96365, 96372, , , 99150, J2001 Also not with 64627: 62310, , Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total only 2010 American Medical Association. All Rights Reserved Ingenix

5 Appendix A: s As discussed in the Reimbursement chapter of this manual, each anesthesia code is assigned a base unit by the American Society of Anesthesiologists (ASA) that reflects the difficulty of the procedure and inherent risks. Base units range from three to 20 units. It should be noted, however, that some payers may revise the base units of certain procedures. CMS also developed base units for anesthesia codes. Base units are used to help calculate payment and should not be included when determining the number of units to be indicated on the claim. Both the CMS and ASA base unit values represent all usual anesthesia services, with the exception of the time actually spent in anesthesia care as well as any modifying factors that may occur. The following table contains the 2010 base units assigned by CMS for anesthesia services Ingenix codes only 2010 American Medical Association. All Rights Reserved. 757

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