1 Preface Summary of Changes Table of Contents Service Contacts November 2014 Replaces: September 2014 S /14
2 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing business with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. The guides are referenced in your provider agreement, and include information that applies to all benefit plans in Iowa and South Dakota unless specified within the text. Explanation of Terminology Wellmark Throughout the guides, the term Wellmark indicates Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. Member Individuals with health coverage through Wellmark are referred to as members. Provider Guide Updates Wellmark s Provider guides are continually updated to bring you the most current information. The following items identify when the guide or section was last changed. The date of the most current update can be found next to the linked guide name on Wellmark.com > Provider > Communications and Resources > Provider Guides. The most current date is printed on the front cover and inside pages. The date of the version replaced is also printed on the front cover. A Summary of Changes page lists all the substantial changes made in the most current updates. The page(s) affected and a brief explanation of the change is linked from the Summary of Changes page to the change within the document. Changed text and most links appear in blue type. Printed Copies of Wellmark s Provider Guides We invite you to print Wellmark s Provider guides from the website. Guide updates are periodically listed in the BlueInk newsletter. You will always find the current version at Wellmark.com > Provider > Communications and Resources > Provider Guides. Current Procedural Terminology (CPT) is copyright 2014 by the 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. CPT is a trademark of the American Medical Association. Blue Cross, Blue Shield, the Cross and Shield symbols, Blue Access, Blue Advantage, BlueCard, Blue Choice, Blue Connections, Classic Blue, Blue Select, and Senior Blue are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark Blue PPO SM, Wellmark Blue HMO SM, Wellmark Blue POS SM, Blue Traditions SM, SimplyBlue SM, EnhancedBlue SM, CompleteBlue SM, PremierBlue SM, and myblue HSA SM are service marks of the Blue Cross and Blue Shield Association. Wellmark is a registered mark and Alliance Select SM is a service mark of Wellmark, Inc. Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association.
3 Anesthesia Services Billing Guide Summary of Changes-February, May, September, and November 2014 Summaries below link to the actual changes in the text. The most recent changes appear in blue. Throughout: (May) Changed Billing Guides to Provider Guides. Page 2: (September) Added section One Procedure Two Anesthesiologists or Two CRNAs. Page 2: (February) With the exception of CPT code 01996,* codes will be required to be submitted with one of the anesthesia modifiers listed. Page 6: (November) Added section Billing for Compounded Drug Refills Used in Implantable Epidural/Subarachnoid Pain Pumps. Service Contacts page: (September) Removed local phone numbers. Service Contacts page: (September) Removed phone numbers listed for Iowa Bankers, UI Care, UI GradCare, and UI Select; and Ford Retirees. *Current Procedural Terminology 2014 American Medical Association. All Rights Reserved.
4 Anesthesia Services Billing Guide Table of Contents I. Introduction... 1 II. Billing Guidelines for Anesthesia Services... 1 Billing Anesthesia for Multiple Surgeries... 1 One Procedure Two Anesthesiologists or Two CRNAs... 2 Reporting the Health of the Patient... 2 Anesthesia Modifiers required on Anesthesia Services... 2 CRNA Services... 3 Teaching Anesthesiologist Payment... 4 III. Anesthesia Modifiers that Affect Payment... 4 IV. Units of Service... 5 ANSI 837 Format for Submitting Units of Service... 5 V. Pain Management Services... 5 Billing for Compounded Drug Refills Used in Implantable Epidural/Subarachnoid Pain Pumps... 6 VI. Qualifying Circumstances... 6 VII. Moderate (Conscious) Sedation... 7 VIII. Cosmetic Surgeries... 7 IX. Summary... 7
5 Scope Information in this guide applies to networks and products offered or administered by Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. As individual benefit plans vary, always verify eligibility and benefits using our secure Web tools on Wellmark.com. Description of anesthesia services This guide provides coding and billing information for anesthesiology services. It clarifies how to bill services performed by CRNAs who are medically directed, employed, or who practice independently. It also covers topics such as how to bill pain management, moderate (conscious) sedation, and anesthesia when multiple surgeries are performed at the same operative session. An anesthesiologist or an independent certified registered nurse anesthetist (CRNA) may bill Wellmark direct for his or her services using the anesthesiology codes found in CPT * ( ). While some surgical CPT codes are appropriate to use when billing anesthesia services (e.g., 36620), the majority of anesthesia services should be billed using codes in the range of Anesthesia services include, but are not limited to, general, regional, monitored supplementation of local anesthesia or other supportive services. An anesthesia service includes: the usual anesthesia preoperative and postoperative visits administration of the anesthetic for the site of surgery anesthesia care during the procedure administration of fluids and/or blood replacement the usual monitoring services, e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry Billing Anesthesia for Multiple Surgeries If you bill for the administration of anesthesia for multiple surgical procedures performed during the same operative session, submit only one anesthesia code. Choose the anesthesia code representing the most complicated procedure. The time reported is the combined total for all the procedures. Note: When add-on anesthesia procedure codes (e.g., 01968,* 01969) are needed to bill the services performed, submit each add-on code in addition to the primary procedure (e.g., 01967). *Current Procedural Terminology 2014 American Medical Association. All Rights Reserved.
6 One Procedure Two Anesthesiologists or Two CRNAs When the first anesthesiologist (MDA) or the first CRNA starts an anesthesia procedure and he/she has to leave the patient to start another anesthesia procedure, and a second anesthesiologist or a second CRNA then finishes the procedure; a claim should be submitted for the anesthesiologist or CRNA who spent the longest length of time with the patient. The amount of time reported on the claim should be the combined total time period of the procedure. Documentation should include the time spent with the patient for either the first and second anesthesiologist or CRNAs. Reporting the Health of the Patient Physical status modifiers distinguish between various levels of complexity of the anesthesia service provided based on the patient s condition, and are represented by the letter P followed by a single digit: P1 P2 P3 P4 P5 P6 a normal healthy patient a patient with mild systemic disease a patient with severe systemic disease a patient with severe systemic disease that is a constant threat to life a moribund patient who is not expected to survive without the operation a declared brain-dead patient whose organs are being removed for donor purposes Anesthesia Modifiers required on Anesthesia Services Physicians must report the appropriate anesthesia modifier to denote whether the service was performed, medically directed, or medically supervised by the physician, or if it represented monitored anesthesia care. Similarly, CRNAs must report the appropriate anesthesia modifier to indicate whether the service was performed with or without supervision by a physician. Anesthesia services ,* with the exception of 01996, will be required to have one of the following anesthesia modifiers: AA AD G8 G9 QK QS QX QY QZ (Anesthesia services performed personally by an anesthesiologist) (Medical supervision by a physician: more than 4 concurrent anesthesia procedures) (Monitored anesthesia care for deep, complex, complicated, or markedly invasive surgical procedure) (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) (Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals) (Monitored anesthesia care services) (CRNA Service: with medical direction by a physician) (Medical direction of one CRNA by an anesthesiologist) (CRNA Service: without medical direction by a physician) *Current Procedural Terminology 2014 American Medical Association. All Rights Reserved.
7 Medically directed/supervised CRNA services CRNA Services When a CRNA and a medically directing or supervising anesthesiologist (MDA) provide services for a single anesthesia procedure, submit claims as follows: Submit separate claims for each practitioner using his/her NPI number Submit the same CPT code and time on both claims Add to the procedure code on the supervising anesthesiologist s claim: Modifier QY Description Medical direction of one CRNA by an anesthesiologist Add the QX modifier to the procedure code on the medically directed CRNA s claim: Modifier QX Description CRNA service; with medical direction by a physician When an anesthesiologist (MDA) medically directs or supervises more than one CRNA, add one of these modifiers to the procedure code on the supervising anesthesiologist s claim: Modifier QK AD Description Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals Medical supervision by a physician: more than four concurrent anesthesia procedures Add the QX modifier to the procedure code on the medically directed CRNA s claim: Modifier QX Description CRNA service; with medical direction by a physician Medically directed/supervised CRNA services Hospital employed/ contracted CRNA services When the supervising anesthesiologist and medically directed/supervised CRNA bill separately, Wellmark pays each practitioner his/her contracted maximum allowable fee (MAF) for the anesthesia service. Hospitals that bill anesthesia services of employed or contracted independently practicing CRNAs must submit charges on a CMS-1500, identifying the CRNA with his or her NPI in field 24J or on the 837 professional electronic claim in loop 2310B/NM109.
8 Independently practicing CRNA Services performed by a CRNA without supervision by a physician should be billed with a QZ modifier. Modifier QZ Description CRNA service: without medical direction by a physician One or two cases Three or four concurrent cases Requirements for special payment rule Teaching Anesthesiologist Payment When a teaching anesthesiologist is involved in a single case, two concurrent cases, or in a single case concurrent with another case paid under medical direction rules with an anesthesia resident, payment can be made based on the anesthesia fee schedule amount, which would be the same as if the anesthesiologist performed the anesthesia services alone. If the anesthesiologist medically directed the provision of anesthesia services in three or four concurrent cases, any of which involved residents, payment can be made for the physician s involvement in the resident case[s] under the medical direction payment policy. Under this policy, payment for the anesthesiologist s service would be 50 percent of the anesthesia fee schedule that applies when an anesthesiologist performs the cases alone. In order for the special payment rule for teaching anesthesiologists to apply: 1. The teaching anesthesiologist (or other anesthesiologists in the same physician group) must be present during all critical or key portions of the anesthesia service. 2. If different teaching anesthesiologists in the anesthesia group are present during the key or critical periods, the performing physician (for purposes of claims reporting) is the teaching anesthesiologist who started the case. 3. The teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) must be immediately available to furnish anesthesia services during the entire procedure. The modifiers listed below affect payment. Modifier AD QY QX QK Definition Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of one CRNA by an anesthesiologist CRNA service; with medical direction by a physician Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
9 Anesthesia time begins when the anesthesiologist begins preparing the patient for surgery and ends when the anesthesiologist is no longer in personal attendance and the patient is safely placed under postanesthesia supervision. Submit number of minutes Base units Submitting units electronically Submit the actual minutes spent providing anesthesia services as the units of service. Wellmark converts the number of minutes submitted into units (15 minutes = 1 unit) and reflects the number of calculated units on your Practitioner Claims Report (PCR). Wellmark rounds up to the next unit for minutes over 15- minute increments (e.g., 31 minutes = 3 units). Do not add anesthesia base units to the actual time you submit. The units field should reflect only the length of time of the service. Base units, as defined by the American Society of Anesthesiologists, are already included in Wellmark s reimbursement. ANSI 837 Format for Submitting Units of Service The ANSI 837 electronic claim format carries the Units of Service in loop 2400, elements SV103 and SV104. To submit anesthesia minutes, element SV103 must contain a value of MJ (minutes) with the number of minutes residing in SV104. The minutes should be submitted as whole numbers (1 through 9999). For example, to submit 45 minutes of anesthesiology services on an electronic claim, in loop 2400, element SV103 should contain MJ and element SV104 should contain 45. Our Medical Department may review the claim to make sure the number of minutes is appropriate for the service provided. If more information is needed to complete this review, we may request medical records. After completing the review, we will finish processing the claim. Pain management means those services defined as such by the American Society of Anesthesiologists Relative Value Guide (RVG) as updated annually in the following categories: pain management procedures intravascular catheterization procedures other venous/arterial access procedures Bill pain management with 1 unit of service on the CMS CPT Code Description 01996* Daily hospital management of epidural or subarachnoid continuous drug administration
10 Post-surgical pain management Submit anesthesia code for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter. Billing for Compounded Drug Refills Used in Implantable Epidural/Subarachnoid Pain Pumps When drugs are compounded for these refills, they will be paid using the method described below: baclofen (Lioresal) bupivacaine (Marcaine, Sensorcaine) clonidine (Duraclon) fentanyl (Sublimaze) Note: This is not an all-inclusive list of such medications. hydromorphone (Dilaudid) morphine(astramorph, Duramorph, Infumorph) sufetanil (Sufenta) ziconotide (Prialt) Guidelines for reimbursement The following guidelines listed below are used to reimburse providers for compounded drugs and the associated services: Use HCPCS code J3490 (Unclassified drugs) with one unit of service and with the KD modifier ( Drug or biological infused through DME [durable medical equipment] ). A description for all J3490 NOC must be included on the CMS 1500 in box 24D or on the 837 professional electronic claim in loop 2400/SV National Drug Code (NDC) codes may be reported in loop 2410/LIN03. Drug-specific J codes should not be billed for these compounded drug mixtures used in epidural/subarachnoid pain pump refills. These true codes do not specifically describe the actual formulations of the drugs used in this compounding process. An invoice may be required for these claims. Wellmark will request an invoice when payment cannot be determined based on the description/ndc codes that were billed. If you do not return the invoice, the claim will not be processed. Include: Name of the drug; Exact total dosage (number or milligrams or micrograms) for that patient; Route of administration (i.e., internal pump ) or the brand name of the pump. Wellmark considers qualifying circumstances (procedure codes in the Medicine section of CPT) part of the surgical procedure and does not pay for these services when billed in addition to the surgery.
11 Sedation with or without analgesia CPT describes moderate (conscious) sedation as a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Bill moderate (conscious) sedation services using a procedure code in the range. Note: CMS National Correct Coding Initiative (CCI) Edits may bundle the codes with another procedure. These services are identified on CMS Web site at Also refer to Appendix G of CPT for a list of codes that include moderate (conscious) sedation services and will not be paid if billed separately. Moderate sedation does not include minimal sedation, deep sedation, or monitored anesthesia care ( *). Refer to CPT for more detailed billing information. If the primary purpose of the surgery is to improve the appearance of a patient, not to restore bodily function or correct a deformity, Wellmark considers the procedure cosmetic and, therefore, noncovered. This guide is a coding and billing resource for the most common anesthesia procedures. If you have questions not addressed in this guide, please call the appropriate provider service number listed on the next page. *Current Procedural Terminology 2014 American Medical Association. All Rights Reserved.
12 Wellmark Blue Cross and Blue Shield of Iowa Wellmark Health Plan of Iowa, Inc. Des Moines, IA Wellmark Blue Cross and Blue Shield of Iowa* Wellmark Health Plan of Iowa, Inc.* Provider Service Federal Employee Program* Admission Notification, Precertification, and Case Management Network Engagement Contracting Opportunities: Pregnancy Program* Disease Management Program* Network Administration* Provides information about: network participation, provider number, address change, application status, credentialing/recredentialing status, and taxpayer identification number change or BlueCard Program* Out-of-state members claim status or payment information: Out-of-state members eligibility information: EC (Electronic Commerce) Solutions* Electronic claims and reports information: Pharmacy Department Wellmark Blue Cross and Blue Shield of South Dakota Sioux Falls, SD Wellmark Blue Cross and Blue Shield of South Dakota* Provider/Customer Service Federal Employee Program* Admission Notification, Precertification, and Case Management Network Engagement Contracting Opportunities: Pregnancy Program* Disease Management Program* Network Administration* Provides information about: network participation, provider number, address change, application status, credentialing/recredentialing status, and taxpayer identification number change BlueCard Program Out-of-state members claim status or payment information: Out-of-state members eligibility information: EC (Electronic Commerce) Solutions* Electronic claims and reports information: Pharmacy Department *You will find links to these areas from our website at Wellmark.com > Contact Us (top right of page). Select For Iowa Providers or For South Dakota Providers.
Preface Summary of Changes Table of Contents Service Contacts October 2014 Replaces: May 2014 S-5781 10/14 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing
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