Fee Schedule - Anesthesia
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1 Fee Schedule - Anesthesia /01/ E Century Ave Ste 1 PO Box 5585 Bismarck ND CPT only copyright 2014 American Medical Association. All rights reserved.
2 Copyright Notice The five character codes included in the North Dakota Fee Schedule are obtained from the Current Procedural Terminology (CPT ), copyright 2014 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of North Dakota Fee Schedules is with WSI and no endorsement by the AMA is intender or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in North Dakota Fee Schedule. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside of North Dakota Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply. CPT is a registered trademark of the American Medical Association. ADA codes are copyright 2014 American Dental Association. All Rights Reserved. Reproduced and distributed under ADA License # CPT only copyright 2014 American Medical Association. All rights reserved.
3 Table of Contents Anesthesia Payment Methodology... 4 Payment Parameters... 5 Code Code CPT only copyright 2014 American Medical Association. All rights reserved.
4 Anesthesia Payment Methodology The medical fee schedule uses the procedure codes and descriptions of the American Medical Association s physicians Current Procedural Terminology (CPT ). Fees are calculated using the Resource Based Relative Values (RBRVS) weights established by the Centers for Medicare & Medicaid (CMS) The medical and hospital fee schedules contain the entire list of CPT identifying codes. The listing of CPT codes in the fee schedules is not a guarantee of payment. WSI shall use the following conversion factor table to determine the maximum allowable fee by multiplying the conversion factor by the relative value unit established in the RBRVS. The Anesthesia Fee Schedule Conversion Factor will be updated each year by the same percentage as the WSI Medical Fee Schedule. Conversion Factor Table Specialty Groups Conversion Factor Anesthesia (Time Units & Risk Units) WSI will pay for professional anesthesia services on a per case basis. WSI shall use the following formula to determine the maximum allowable reimbursement for each anesthesia case: Basic Time Physical Conversion Maximum Value + Units + Status X Factor = Allowable Units Modifier Reimbursement One time unit equals 15 minutes, regardless of the length of the procedure. Under the per case payment methodology: When an MDA or a CRNA personally performs a case, the full case payment will be made to that provider When a CRNA performs a case under the Medical Direction of an MDA: o The CRNA is paid for 50% of the per case amount o The MDA is paid for 50% of the per case amount CPT only copyright 2014 American Medical Association. All rights reserved.
5 Anesthesia Fee Schedule Payment Parameters WSI requires that the following anesthesia payment modifiers be used as appropriate: AA MDA personally performs a case AD MDA medically supervising more than 4 concurrent anesthesia procedures QY MDA medically directing one CRNA QK MDA medically directing 2 4 CRNAs QZ CRNA performs case without medical direction QX CRNA performs case with medical direction WSI will allow payment for the following patient status modifiers: P3 A patient with severe systemic disease one additional unit is paid P4 A patient with severe systemic disease that is a constant threat to life two additional units are paid P5 A moribund patient who is not expected to survive without the operation three additional units are paid For medically directed cases, both the CRNA and MDA may use these modifiers. There will be no separate payment for patient status modifiers P1, P2 & P6. WSI will allow payment for the following add on anesthesia service CPT codes: Anesthesia for patients of extreme age, under 1 year and over 70 one additional unit is paid Anesthesia complicated by utilization of total body hypothermia 5 additional units are paid Anesthesia complicated by utilization of controlled hypothermia 5 additional units are paid Anesthesia complicated by emergency conditions two additional units are paid For medically directed cases, both the CRNA and MDA may use these add on codes. An MDA filing a claim for medical direction of a CRNA must meet all of the seven Medical Direction criteria as required by CMS. The MDA must: Perform a pre-anesthetic examination and evaluation; Prescribe the anesthesia plan; Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence; Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist; Monitor the course of anesthesia administration at frequent intervals; Remain physically present and available for immediate diagnosis and treatment of emergencies; and CPT only copyright 2014 American Medical Association. All rights reserved.
6 Provide indicated post-anesthesia care All claims for anesthesia services must be billed on a 1500 claim form. The actual number of anesthesia minutes will be reported as the number of units. The payment modifiers (AA, QY, QK, QZ & QX) must be in the first modifier position on the claim. Claims submitted without a payment modifier will be returned to the provider. Patient status modifiers must be in the second modifier position on the claim. In unusual circumstances when it is medically necessary for both the CRNA and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report the service using the AA modifier and the CRNA would use QZ. When both a CRNA and an MDA claim using these modifiers are received for a single anesthesia case, WSI will request documentation to support payment of the full fee for both providers. Non Anesthesia services, such as insertion of catheters, placement of central venous and arterial lines, intubations, pain management services, etc. are paid under the WSI Medical Fee Schedule. They are billed as procedures with a unit of one and no anesthesia payment or patient status modifiers. CPT only copyright 2014 American Medical Association. All rights reserved.
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