Anesthesia Services Effective 12/1/06

Transcription

1 EqualityCareNews October 2006 Coverage ATTENTION PROVIDERS Anesthesia Services Effective 12/1/06 CMS-1500 Bulletin EqualityCare covers anesthesia only when administered by a licensed anesthesiologist or a certified registered nurse anesthetist (CRNA) who remains in attendance for the sole purpose of rendering anesthesia in order to afford the patient anesthesia care deemed optimal during any procedure. The American Society of Anesthesiologists (ASA) relative value guide is accepted as the basis for coding and definition of anesthesia provided to Medicaid patients. Billing Anesthesia services may be billed either electronically or on a CMS-1500 claim form. Refer to billing instructions at wyequalitycare.acs-inc.com or in the EqualityCare CMS-1500 Billing Module. Specific Instruction for Anesthesia Billing When billing ASA procedure codes, enter actual minutes for procedures where time is necessary. For example, enter 65 minutes, rather than 1 hour 5 minutes. When billing using a paper claim form, enter the total time in minutes, in Box 24G of the CMS-1500 form. A specific diagnosis code must be used. REIMBURSEMENT FOR ANESTHESIA Anesthesia payments will be the lower of billed charges or a calculated fee. The Medicaid Management Information System (MMIS) calculates anesthesia reimbursement by adding Basic Value, plus Time Units and multiplying the total number of anesthesia values by a dollar conversion factor. That fee is then adjusted according to the appropriate anesthesia modifier.

2 A Basic Value is assigned for anesthetic management of most surgical procedures and is related to the complexity of the procedure. This basic value includes all usual anesthesia included in the Basic Value are the usual pre-operative and postoperative visits, the administration of fluids and /or blood products incident to the anesthesia care and interpretation of non-invasive monitoring. Time Units Time reporting for EqualityCare is computed at the rate of one time unit for each fifteen-minute or fraction therefore. Fractions of time are always rounded up to the next full number. Payment calculation per MMIS system = procedure anesthesia base units plus time units multiplied by the anesthesia conversion factor. Important Note: Anesthesia units must be billed in minutes. Do not convert or change time by dividing by 15, the MMIS does this automatically when the claim is processed. Documentation Requirements for Anesthesia: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or an equivalent area and ends when the anesthesiologist is no longer in personal attendance. Anesthesia care terminates when the patient may be safely placed under post-anesthesia supervision. Begin and end times must be documented in the anesthesia record and must be legible. Anesthesia is a global service just as the surgical procedure for which it is given. No pre- or post-operative services will be recognized for separate payment, including those for: a. Pain Management on the same day as surgery. b. Routine monitoring is included in the primary anesthesia and not reimbursed separately. For specific information regarding routine monitoring, refer to the current version of the ASA relative value guide. c. Larygnoscopy codes 31505, and are incidental or included within the anesthesia time. d. Any anesthesia substance administered at the time of the procedure for circumcision, cannot be billed separately as this is considered part of the global package. Obstetrical Anesthesia Time Reporting Neuraxial labor analgesia/anesthesia for planned vaginal delivery will be reimbursed as a global fee per the fee schedule and should be billed as 1 unit, not the number of minutes.

3 Global fee includes establishing and maintaining the anesthesia for the time the client requires it. If the anesthesia should continue into the next day, use procedure code When billing obstetrical anesthesia, indicate total time, in minutes. If two anesthesia codes are billed on the same day, (i.e. tubal ligation following vaginal deliver), documentation must be submitted with the claim to support the necessity of these services. In some circumstances, pain management services extend to the day following the C-section. In such cases, coverage will be provided through use of the following code: daily follow-up and management of epidural analgesia EqualityCare does not allow CPT on the same day as placement of an epidural catheter. When multiple procedures are performed during a single anesthetic administration, Equality- Care will pay the basic value for only one anesthesia procedure. When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported. The time reported is the combined total for all procedures. Anesthesia for multiple obstetrical procedures may be paid the basic values for both procedures in the following circumstances. Neuraxial analgesia/anesthesia for planned vaginal delivery which becomes a Cesarean delivery. Use code to begin the procedure. When C-section is imminent, discontinue use of and change to code and continue on with straight time as for a general surgery. Neuraxial analgesia/anesthesia for planned vaginal delivery followed by tubal ligation on same or the next day following delivery. Use code for delivery. Use code (new code) Intraperitoneal Lower Abdomen, Tubal ligation/ Transection.

4 ANESTHESIA MODIFIERS Report all anesthesias with the anesthesia five-digit procedure code (00100 through 01999) plus the addition of physical status modifier. The use of other optional modifiers may be appropriate. Physical Status Modifiers Physical Status modifiers are represented by the initial letter P followed by a single digit from 1 to 6. Example: P1 These modifiers indicate various levels of complexity of the anesthesia service provided. Modifier Description Reimbursement P1 A normal healthy patient. No change P2 A patient with mild systemic disease. No change P3 A patient with severe systemic disease. Additional 5% P4 P5 P6 A patient with severe systemic disease that is a constant treat to life. A moribund patient who is not expected to survive without the operation. A declared brain-dead patient whose organs are removed for donor purposes. Additional 10% Additional 15% Not covered When billing for anesthesia, indicate the appropriate physical status modifier. If a Physical Status Modifier is billed, additional payment if appropriate will be added to the claim payment. A service that is rarely provided, unusual, variable, or new may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service.

5 Additional items which may be included are: complexity of symptoms final diagnosis pertinent physical findings diagnostic and therapeutic procedures concurrent problems follow-up care EqualityCare follows the correct coding initiatives of Medicare. Medicare considers these codes B status or bundled codes. The anesthesia of special circumstance is figured into the complexity status of the patient (physical status modifiers), the RVU of the procedure, and the time required for the procedure. Therefore, the special circumstance codes are not reimbursed separately. Anesthesiologists and CRNA s are not required to request prior authorization (PA) directly from EqualityCare for any anesthesia procedure. When billing for surgical procedures which require informed consent, a copy of the surgeon s consent form must be attached to the claim. This would include hysterectomy, sterilization and therapeutic abortion procedures. If you have additional questions regarding billing or covered services, please contact the ACS Provider Relations Unit at (307) or toll free at (800) Call center hours are Monday through Friday from 9am-5pm.

6 Important Changes! Please read! ACS, Inc P.O. Box 667 Cheyenne, WY PHONE: (800) IN CHEYENNE: (307) FAX: (307) We re on the Web!