Status Active. Reimbursement Policy Section: Anesthesia Services Policy Number: RP - Anesthesia Anesthesia Effective Date: June 1, 2015

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1 Status Active Reimbursement Policy Section: Anesthesia Services Policy Number: RP - Anesthesia Anesthesia Effective Date: June 1, 2015 Anesthesia Policy Description: Definitions: This policy addresses coverage and reimbursement for anesthesia services. Full-time anesthesia: Anesthesia services are provided personally by the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) to an individual patient. Blue Cross also considers anesthesia services provided by independent CRNA and physician-employed CRNA to be fulltime if the criteria in this policy are met and medical direction is not provided by a physician. The anesthesiologist or CRNA is physically present in the specific operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure. The anesthesiologist or CRNA may leave the specific operating suite to perform necessary administrative duties. However, the anesthesiologist or CRNA does not perform other revenue-generating procedures when billing full-time anesthesia services. This definition includes one-onone supervision of a CRNA present in the same operating suite. Part-time (Medically Directed) Anesthesia: Medically directed anesthesia services are provided by the anesthesiologist or CRNA when he or she is supervising two or more CRNAs. The anesthesiologist or CRNA may perform the induction and emergence but is not necessarily present during the entire operative session and may be supervising two or more procedures at the same time. Modifiers: AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures 1 Anesthesia

2 QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals QS Monitored anesthesiology care services (can be billed by a qualified nonphysician anesthetist or a physician) QX Qualified nonphysician anesthetist with medical direction by a physician QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist QZ CRNA service: without medical direction by a physician P1 A normal, healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is a constant threat to life P5 A moribund patient who is not expected to survive without the operation P6 A declared brain-dead patient whose organs are being removed for donor purposes Policy: American Society of Anesthesiologist (ASA) codes Blue Cross accepts the CPT (ASA), codes, for anesthesia services billed on the 837P claim format. Blue Cross does not accept, thus will deny, surgical codes submitted with anesthesia modifiers. All services for the same operative session should be submitted on the same claim. ASA codes are restricted to anesthesiologists and CRNAs. Time Designation/Submission Anesthesia time should be indicated on the 837P claim format in the unit(s) field of the 837P record. Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for the induction of anesthesia in the operating room, or an equivalent area, and ends when they are no longer in personal attendance. Anesthesia time should be coded as minutes in the units of service field. (One unit equals one minute.) Modifier use Modifiers are required to identify the practitioner (anesthesiologist or CRNA), the circumstance (full or part-time), medical direction and if appropriate, patient physical status. 2 Anesthesia

3 The HCPCS full or part-time modifiers (AA, AD, QK, QS, QX, QZ and QY) should be listed in the first modifier position. The anesthesia modifiers should only be reported with the CPT anesthesia codes Other services (such as nerve blocks), may be performed by an anesthesiologist or CRNA, but should not be submitted with an anesthesia modifier. Full-time: Use modifier AA for full-time physician (anesthesiologist) services. Modifier QZ would be used for full-time CRNA services. Part-time: Use modifier -AD or -QK for the medical direction provided by a physician (part-time services). Use modifier -QY for part-time medical direction of one CRNA by an anesthesiologist. Use modifier -QX for medically directed CRNA services (part time). Modifier -QS would be used for part-time monitored anesthesia care. Physical Status Six levels are currently recognized for patient physical status that may be used to distinguish various levels of complexity of the anesthesia service provided. These modifiers are reported in the second modifier position, on the same line as the anesthesia service code. Additional reimbursement may be made based on the patient physical status. See the corresponding eligible base units below. Modifier Base Units Description P1 0 A normal, healthy patient P2 0 A patient with mild systemic disease P3 1 A patient with severe systemic disease P4 2 A patient with severe systemic disease that is a constant threat to life P5 3 A moribund patient who is not expected to survive without the operation P6 0 A declared brain-dead patient whose organs are being removed for donor purposes Qualifying Circumstances In accordance with CPT, the following circumstances are recognized for submission of risk. These codes must be billed on a separate line from the anesthesia service. However, qualifying circumstance codes billed without an ASA service on the same claim will be rejected. The 3 Anesthesia

4 corresponding eligible base units that may be allowed are listed below. Anesthesia risk factors will be priced independently of the anesthesia line for easier posting of payments to accounts and greater accuracy of payments. Code Units Description Anesthesia for patient of extreme age; younger than 1 year and older than Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypotension Anesthesia complicated by emergency conditions (specify) NOTE: An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat of life or body part. Anesthesia Reporting for Multiple Surgery Code anesthesia services associated with multiple or bilateral surgical procedures performed during the same operative session with the single anesthesia code that has the highest base unit value. If multiple ASA codes are submitted for the same operative session, the lower valued ASA code(s) will be denied. Monitored Anesthesia Care Monitored anesthesia care (MAC) refers to instances in which an anesthesiologist has been called on to provide specific anesthesia services to a particular patient undergoing a planned procedure. In this case, the physician performs a preanesthetic examination, is physically present in the operating suite, monitors the patient s condition, makes medical judgments regarding the patient s anesthesia needs, and is prepared to furnish anesthesia service as necessary. For those circumstances under which such care is medically necessary and requested by the performing surgeon, Blue Cross will allow submission for MAC the same as for any other anesthesia service. Use modifier -QS for monitored anesthesia services. Local Anesthesia Local anesthesia, such as a nerve block, is included in the surgical procedure code. Do not submit a separate charge for this service. Epidural Anesthesia for a Surgical Procedure 4 Anesthesia

5 The insertion and administration of an epidural by an anesthesia provider for anesthesia during a surgical procedure should be reported with the appropriate anesthesia code. Codes 62311, or should not be submitted. Epidural or Injection Anesthesia for Postoperative Pain Management The insertion of an epidural catheter for pain management services (nerve block) administered prior to induction by general anesthesia for post-operative pain may be allowed in some circumstances. Generally, the blocks may only be allowed separately when administered in conjunction with knee or shoulder surgery. If meeting this criteria, the nerve block should be billed with procedure modifier 59, indicating a distinct procedural service. The block (62310, 62311, 62318, 62319, 64415, 64416, 64445, 64446, 64447, 64448, 64449, 64450) must be administered by a qualified provider. Time units are not appropriate for these codes (unit must be one [1]), and anesthesia modifiers should not be submitted. Separate documentation is required for regional nerve blocks when administered before general anesthesia to distinguish it from the anesthesia report/record. Anesthesia for Nerve Blocks Anesthesia services for diagnostic or therapeutic nerve blocks and injections are submitted under codes or only when a different provider performs the block or injection. Daily Management of Epidural Drug Administration Daily management of an epidural catheter performed on the same date as the insertion of the catheter is considered to be included in the insertion and should not be reported separately. Subsequent daily management of epidural drug administration in the inpatient setting, including daily visits and removal of the epidural catheter, may be reported using CPT code (daily hospital management of epidural or subarachnoid drug administration). Do not submit anesthesia modifiers or time for epidural daily management. Removal of the epidural catheter alone does not constitute daily management. If the only service performed is removal of the catheter, code should not be reported. Subsequent daily management of 5 Anesthesia

6 an epidural catheter performed in a setting other than inpatient hospital should be reported using the appropriate Evaluation and Management code. Epidural Anesthesia for Labor and Delivery Insertion Only When a provider performs the insertion of an epidural catheter for continuous analgesia, but does not participate in the ongoing management and monitoring of the epidural analgesia for labor and delivery, the claim should be for the insertion service only (code 62319). Time units are not appropriate for code 62319, and anesthesia modifiers should not be submitted. Insertion and Management When a provider inserts the epidural catheter and participates in ongoing management and monitoring of the patient's epidural analgesia, the anesthesia code and (if applicable) should be reported for the complete service using the appropriate anesthesia modifier, with anesthesia time units for actual face-toface time. It would not be appropriate to report for the insertion of the catheter in addition to the epidural management The emergency qualifying circumstance code (99140) applies only to cases where a delay in treatment would result in an increased risk to life or body part, according to the ASA Relative Value Guide. Do not confuse an inconvenient case with emergencies, such as a surgery that takes place on the weekend or after normal business hours. As such, will be denied if billed with normal deliveries. Management Only In many cases, a physician will insert the epidural catheter, but a CRNA is responsible for the ongoing management and monitoring of the patient s epidural analgesia. When this is the case, the CRNA should submit the anesthesia code (if applicable) and using the appropriate anesthesia modifier, with anesthesia time units for actual face-to-face time. Moderate (Conscious) Sedation The physician who performs a procedure may bill moderate sedation, codes , in addition to billing the procedure. The use of these codes requires and includes an independent trained observer. The observer is not eligible to bill for anesthesia. Do not submit an anesthesia modifier with these codes. 6 Anesthesia

7 When a second physician, other than the healthcare professional performing the procedure, provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center) the second physician reports Codes may not be reported in a non-facility setting (e.g., office). Providers should not submit with procedures that include conscious sedation as an inherent part of providing the procedure. These procedures are listed in Appendix G of the CPT manual. Patient Controlled Analgesia Blue Cross does not reimburse separately for patient controlled analgesia because postoperative pain control has already been included in the reimbursement of the surgical fee, which was paid to the performing surgeon. Patient controlled analgesia is also given to patients who have not had surgery (such as cancer patients) for pain control. It will be covered in such cases. Standby Anesthesia standby occurs when an anesthesiologist or CRNA is present in case his or her services are required for anesthesia, but otherwise performs no medical intervention. Blue Cross does not cover anesthesia standby. Standby services (99360) are considered ineligible and should not be billed to Blue Cross or the patient. Cardioversion Restriction Cardioversion, CPT code (cardioversion, elective, electrical conversion of arrhythmia; external) will not be allowed if submitted by a certified registered nurse anesthetist. Diagnosis Coding Use ICD-9-CM diagnosis codes. Select the diagnosis code that best describes the reason for the surgery based on the patient s medical record. Diagnosis code V50.1, plastic surgery for unacceptable cosmetic surgery appearance, may be submitted when the patient has requested elective surgery and that is the only surgery performed during an operative session. Dental Anesthesia Dental anesthesia provided by an oral maxillofacial dental providers must be reported using the appropriate dental anesthetic HCPCS code, such as D9220, deep sedation/general anesthesia - first 30 minutes. ASA codes will be denied if submitted. 7 Anesthesia

8 Documentation Submission: Coverage: The anesthesia record (either at the facility or the provider s office) must clearly identify the professional or professionals providing the anesthesia service. In order to justify charges, both the CRNA and anesthesiologist signatures must be present for medically directed care. Full-time anesthesia will be allowed at the full time negotiated rate. Part-time anesthesia will be allowed at the part time negotiated rate. Only one ASA code (highest unit code) should be reported for the entire operative session. If more than one is submitted the additional ASA code(s) will be denied. ASA code submission must be reported in minute increments. Additional units may be allowed based on appropriate submission of a qualifying circumstance code and/or physical status modifier. The following applies to all claim submissions. All coding and reimbursement is subject to all terms of the Provider Service Agreement and subject to changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-9-CM), only codes valid for the date of service may be submitted or accepted. Reimbursement for all Health Services is subject to current Blue Cross Medical Policy criteria, policies found in the following sections and all other provisions of the Provider Service Agreement (Agreement). In the event that any new codes are developed during the course of Provider's Agreement, such new codes will be paid according to the standard or applicable Blue Cross fee schedule until such time as a new agreement is reached and supersedes the Provider's current Agreement. All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider. Coding: The following codes are included below for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. CPT/HCPCS Modifier: AA, AD, QK, QS, QX, QY, QZ, P1, P2, P3, P4, P5, P6 ICD-9 Diagnosis:V Anesthesia

9 ICD-10 Diagnosis: ICD-9 Procedure: ICD-10 Procedure: HCPCS: , 62310, 62311, 62318, 62319, 64415, 64416, 64445, 64446, 64447, 64448, 64449, 64450, 92960, 99100, 99116, 99135, 99140, , ,sss Deleted Codes: Policy History: Initial Committee Approval Date: December 2, 2014 Cross Reference: Most Recent History: Current Procedural Terminology (CPT ) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Copyright 2015 Blue Cross Blue Shield of Minnesota. 9 Anesthesia

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