Perioperative Charge Process
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- David Richardson
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1 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 6. Supplies 7. Drugs 8. Post PACU Care Pre op Prep and Care: Anesthesia: The pre op care includes the starting of IV s, admin of drugs, scrubbing and shaving of the Patient. Pre op antibiotic IV therapy is separately billable as a Nursing Service if there is medical justification and a Physician order. It is not appropriate to charge for pre op care, the majority of hospitals have a cost center dedicated to this process; zero charges are used for the recording of workload. There are six different types of anesthesia: 1. Local 2. Block 3. Epidural 4. Conscious Sedation 5. Monitored Anesthesia Care 6. General Anesthesia services can be either charged individually for supplies, drugs and gases, more common is a time based charge for the type of anesthesia provided; some managed care contracts do not allow the combination of both an itemized anesthesia service with a time based charge. CPT and CMS regulations (appendix G CPT and CCI edits) provide a schedule of procedures where the professional anesthesia service is not separately billable from the procedure. Timing of anesthesia (CS, MAC and General) charges is based on the start / stop time recorded on the anesthesia record. The base time period is 30 minutes, with an add on charge for each additional 15 minutes, add on periods are charged after the first 5 minutes of usage within the period. Anesthesia technical services are billed using revenue code PARA Healthcare Financial Services September 2011 Page 1
2 Operating Room Time Charges: The operating room costs are classified into three different components, which are relieved by billing a time based level charge. The components of the OR room costs are: 1. Room set up time 2. Staff surgical time charge (Nurses, Tech and First Assistant) charges 3. Rental / special equipment charges PARA recommends that the OR time charge be based on levels which are determined by the setup, Staff and equipment charges. The levels (1 5) are determined by the number of Staff in the surgery suite, plus a level bump for set up time greater than 30 minutes, or special equipment rental or usage. Set up Time OR Staff Rental / Special Equip OR Level Base Time Period Add on Time Period < 30 Minutes 1 N 1 30 minutes 15 minutes < 30 Minutes 2 N 2 1st hour 15 minutes < 30 Minutes 3 Y 4 1st hour 15 minutes > 30 Minutes 3 y 5 1st hour 15 minutes > 30 Minutes 4 y 6 1st hour 15 minutes OR room time charges are based on the start / stop surgical time on the anesthesia record, addon periods are charged after the first 5 minutes of usage within a period. OR room charges are billed using revenue code 0360, the HCPCS codes are coded by HIM. Equipment Charges: Special and rental equipment are usually packaged into the OR room time charge by bumping a level, some Fiscal Intermediaries will allow the billing of equipment charges on a OR line on the UB04 claim form, rev code PARA Healthcare Financial Services September 2011 Page 2
3 Recovery / Post Anesthesia Care Unit: The required time a Patient spends in the PACU is 1 hour for general anesthesia, with a Nurse to Patient ratio of 1:1. After the Patient is attended for the minimum period and the Nurse assessment determines the Patient requires a lower staffing ratio, a Nurse can attend to 2 Patients. MAC anesthesia Patients are to be observed for a minimum of 30 minutes. Children are usually 100% 1:1 Nurse staff ratio. Charges for PACU should be set as follows: 1. PACU 1 st hour 1:1 Nurse staff ratio 2. PACU add 15 minutes 1:1 Nurse staff ratio 3. PACU add 15 minutes 1:2 Nurse staff ratio Timing of the PACU charges are based on the PACU admit / discharge times recorded on the PACU record. Medical Supplies: There are seven types of supplies used in the OR, some of which should not be charged to the Patient. The supplies and their billing status is as follows: 1. Routine items Low cost, bulk stock items, (band aids, syringes, wipes, gowns, gloves, drapes and packs) are not to be charged, the cost is to be billed using the OR time charge. 2. Sterile higher cost items, are to be charged, they are itemized on the charge form; multiple units are allowed, these items are to be billed with a C HCPCS code (if possible) and 0272 (sterile supply) rev code. 3. DME exempt These are DME items which can be billed to the Medicare program, they include orthotics (splints, braces, collars and belts), these items are billed using an L series HCPCS code and a 0274 (orthotic) rev code. 4. DME non exempt Non billable DME items (crutches, canes and walkers) are not to be billed to the Medicare program on a bill type UB Implants Hard items which remain in the Patient post procedure, these items may have a C HCPCS code and are to be billed using a 0278 (implant) rev code. 6. IOL lenses Billed using a C (if possible) HCPCS code, and a 0276 (IOL) rev code. High cost lenses can be billed to the Patient (lens cost less the $150 Medicare allowance). 7. Pacemakers Billed using a C (required) HCPCS code and a 0275 or 0278 rev code. PARA Healthcare Financial Services September 2011 Page 3
4 Drugs: All drugs are to be charged, multiple units allowed, the Nursing service to administer the drugs is not billable. Post PACU Care: Routine care provided to a Patient post PACU and prior to discharge is not separately billable to the Medicare Program. If a Patient is to be admitted to observation or inpatient status, a Interqual type of evaluation is required for admission. Observation care is billed per hour, at 1/24 th of the semi private room rate, with a maximum of 48 hours, Medicare will not pay for observation the day of or day after a outpatient surgical or diagnostic procedure (APC Status T), a portion of the regulation is pasted below with a link to the complete billing regulation. hcfs.com/pde/documents/cmsobservationbillingrulesafterjan1st2008.pdf PARA Healthcare Financial Services September 2011 Page 4
5 Charge Process Worksheet: Pre / Post PACU + Set up Time Minutes Operating Room Staff Extensive Equipment Use < Yes 1 31 > No 0 91 > OR Level Determination # of Pts Pre / Post / SU OR Staff Equipment Total OR Level 1st Hour time charge time charge Anesthesia Type Time Basis 1st Hour / Initial Procedure Hours / Subsequent procedures General MAC IV Sedation Epidural One time N/A Block One time N/A Local One time N/A Pain Per Injection PACU Nurse Patient Ratio 1st Hour time charge time charge 1:1 1:2 ICU Holding PARA Healthcare Financial Services September 2011 Page 5
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Iowa Wellness Plan Benefits Coverage List Service Category Covered Duration, Scope, exclusions, and Limitations Excluded Coding 1. Ambulatory Services Primary Care Illness/injury Physician Services Should
Subject: Bundled Services and Supplies
Blue Cross and Blue Shield of Georgia Inc, and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (hereinafter referred to collectively as BCBSGA ) Professional Reimbursement Policy Subject: Bundled
Modifier Reference Policy
Policy Number 2015R0111C Annual Approval Date Modifier Reference Policy 11/12/2014 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for