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Chapter 4: Anesthesia Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Payment policies:
All anesthesia services
Base and time units payment method for anesthesia
RBRVS payment method for anesthesia
Team care (Medical direction of anesthesia)

More info:
Related topics

 


Definitions

CPT® and HCPCS code modifiers mentioned in this chapter:

–25

Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure

Payment is made at 100% of the fee schedule level or billed charge, whichever is less.

–47

Anesthesia by surgeon

–99

Multiple modifiers

This modifier should only be used when two or more modifiers affect payment.  Payment is based on the policy associated with each individual modifier that describes the services performed.  For billing purposes, only modifier –99 should go in the modifier column, with the individual descriptive modifiers that affect payment listed elsewhere on the billing form.

–AA

Anesthesia services performed personally by anesthesiologist

–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

–QK

Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals

–QX

CRNA service: with medical direction by a physician

–QY

Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

–QZ

CRNA service: without medical direction by a physician


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Payment policy: All anesthesia services

Who must perform these services to qualify for payment

Payment for anesthesia services will only be made to:

  • Anesthesiologists, and
  • Certified registered nurse anesthetists.

Services that can be billed

Most anesthesia services are paid with base and time units. These services should be billed with CPT® anesthesia codes 00100 through 01999 and the appropriate anesthesia modifier.

Some selected services are paid using the RBRVS method.

Note: For information on base and time units and RBRVS methods for anesthesia services, see the other payment policy sections of this chapter.

Services that aren’t covered

Anesthesia isn’t payable for procedures that aren’t covered.

Link: Refer to Payment Policies Appendix F for a list of noncovered procedures.

The insurer doesn’t cover anesthesia assistant services.

Payment for CPT® codes 99100, 99116, 99135, and 99140 is considered bundled and isn’t payable separately.

CPT® physical status modifiers (–P1 to –P6) and CPT® 5-digit modifiers aren’t accepted.


Requirements for billing

Anesthesia add-on codes

Anesthesia add-on codes must be billed with a primary anesthesia code.  There are three anesthesia add-on CPT® codes: 01953, 01968, and 01969:

  • Add-on code 01953 should be billed with primary code 01952,
  • Add-on codes 01968 and 01969 should be billed with primary code 01967,
  • Add-on codes 01968 and 01969 should be billed in the same manner as other anesthesia codes paid with base and time units.

Note: Providers should report the total time for the add-on procedure (in minutes) in the “Units” column (Field 24G) of the CMS-1500 form.

Anesthesia for burn excisions or debridement (CPT® add-on code 01953)

The anesthesia add-on code for burn excision or debridement must be billed as follows:

If the total body surface area is… Then the primary code to bill is: And the units to bill
of add-on code 01953 is:
Less than 4 percent 01951 None
5 - 9 percent 01952 None
Up to 18 percent 01952 1
Up to 27 percent 01952 2
Up to 36 percent 01952 3
Up to 45 percent 01952 4
Up to 54 percent 01952 5
Up to 63 percent 01952 6
Up to 72 percent 01952 7
Up to 81 percent 01952 8
Up to 90 percent 01952 9
Up to 99 percent 01952 10

Anesthesia base units

List only the time in minutes on your bill.  Don’t include the base units (L&I’s payment system automatically adds the base units).

Note: Most of L&I’s anesthesia base units are the same as the units adopted by CMS.  L&I differs from the CMS base units for some procedure codes based on input from the ATAG (see more about the ATAG in “Additional information: How anesthesia payment policies are established,” below).

Link: The anesthesia codes, base units, and base sources are listed in the Professional Services Fee Schedule, available at www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Anesthesia time

Anesthesia must be billed in one-minute time units.  Anesthesia time:

  • Begins when the anesthesiologist or CRNA starts to physically prepare the patient for the induction of anesthesia in the operating room area (or its equivalent), and
  • Ends when the anesthesiologist or CRNA is no longer in constant attendance (when the patient can be safely placed under postoperative supervision).

Anesthesia billing code modifiers for anesthesia paid with base and time units

When billing for anesthesia services paid with base and time units, anesthesiologists and CRNAs should use the CPT® or HCPCS modifiers in the following table.

Note: For complete modifier descriptions and instructions, refer to a current CPT® or HCPCS book.

Note: Except for modifier –99, the modifiers listed in the following table aren’t valid for anesthesia services paid by the RBRVS method.

For use by: CPT® or HCPCS code modifier Brief description Notes:
Anesthesiologists and CRNAs –99 Multiple modifiers

Use this modifier when 5 or more modifiers are required.
Enter –99 in the modifier column on the bill. 
List individual descriptive modifiers elsewhere on the billing document.
Anesthesiologists –AA Anesthesia services performed personally by anesthesiologist
–QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individual Payment based on policies for team services (see “Team care” payment policy at the end of this chapter).
–QY Medical direction of 1 CRNA for a single anesthesia procedure Payment based on policies for team services (see “Team care” payment policy at the end of this chapter).
CRNAs(1) –QX CRNA service: with medical direction by a physician Payment based on policies for team services (see “Team care” payment policy at the end of this chapter).
–QZ CRNA service: without medical direction by a physician(1) Maximum payment is 90% of the maximum allowed for physician services.

(1) Bills from CRNAs that don’t contain a modifier are paid based on payment policies for team services (see “Team care” payment policy at the end of this chapter).

Payment limits

Payment for local, regional or digital block, or general anesthesia administered by the surgeon is included in the RBRVS payment for the procedure.

Note: Patient acuity doesn’t affect payment levels.

Services billed with modifier –47 (anesthesia by surgeon) are considered bundled and aren’t payable separately.

Services billed with CPT® 5-digit modifiers and physical status modifiers (–P1 through –P6) aren’t paid.

CRNA services are paid at a maximum of 90% of the allowed fee that would be paid to a physician.

Note: CRNA services shouldn’t be reported on the same CMS-1500 form used to report anesthesiologist services.

Links: For licensed nursing rules, see WAC 296-23-240.

For licensed nursing billing instructions, see WAC 296-23-245.

For detailed billing instructions, including examples of how to submit bills, refer to L&I’s CMS-1500 billing instructions (publication F248-094-000).

Additional information: How anesthesia payment policies are established

Anesthesia payment policies are established by L&I with input from the Reimbursement Steering Committee (RSC) and the Anesthesia Technical Advisory Group (ATAG).

The RSC is a standing committee with representatives from L&I, DSHS, and HCA. The ATAG includes anesthesiologists, certified registered nurse anesthetists, and billing professionals.


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Payment policy: Base and time units payment method for anesthesia

How to calculate anesthesia payment paid with base and time units

Providers are paid the lesser of their charged amount or L&I’s maximum allowed amount.

The maximum payment for services provided by a CRNA is 90% of the maximum payment for a physician.

For services provided on or after July 1, 2012, the anesthesia conversion factor is $48.30 per 15 minutes ($3.22 per minute).

Link: The anesthesia conversion factor is published in WAC 296-20-135 .

The maximum payment for anesthesia services paid with base and time units is calculated using the:

  • Base value for the procedure, and
  • Time the anesthesia service is administered, and
  • L&I anesthesia conversion factor.

To determine the maximum payment for physician services:

  • Multiply the base units listed in the fee schedule by 15, then
  • Add the value from step 1 to the total number of whole minutes, then
  • Multiply the result from step 2 by $3.22.
    Example: CPT® code 01382 (anesthesia for knee arthroscopy) has three anesthesia base units. If the anesthesia service takes 60 minutes, the maximum physician payment would be calculated as follows:
    • 3 base units x 15 = 45 base units,
    • 45 base units + 60 time units (minutes) = 105 base and time units,
    • Maximum payment for physicians = 105 x $3.22 = $338.10.

Payment policy: RBRVS payment method for anesthesia

Which services are paid using the RBRVS method

Some services commonly performed by anesthesiologists and CRNAs are paid using the RBRVS payment method, including:

  • Anesthesia evaluation and management services, and
  • Most pain management services, and
  • Other selected services.

Injection code treatment limits

If the injection type is… Then the treatment limit is:
Epidural and caudal injections of substances other than anesthetic or contrast solution Maximum of 6 injections per acute episode are allowed.
Facet injections Maximum of 4 injection procedures per patient are allowed.
Intramuscular and trigger point injections of steroids and other nonscheduled medications and trigger point dry needling (see more explanation below this table) Maximum of 6 injections per patient are allowed.

Dry needling is considered a variant of trigger point injections with medications.  It is a technique where needles are inserted (no medications are injected) directly into trigger point locations, as opposed to the distant points or meridians used in acupuncture.

Note: L&I doesn’t cover acupuncture services (see WAC 296-20-03002 ).

Links: Details regarding treatment guidelines and limits for the injections listed above can also be found in WAC 296-20-03001 (for example, dry needling follows the same rules as trigger point injections).

For information on billing for medications, see the Medication Administration and Injections chapter.

Requirements for billing

Dry needling of trigger points should be billed using trigger point injection codes.

The office notes or report must document the objective and subjective findings used to determine the need for the procedure and any future treatment plan or course of action.

When billing for services paid with the RBRVS method, enter the total number of times the procedure is performed in the Units column (Field 24G on the CMS-1500 form).

Link: Maximum fees for services paid by the RBRVS method are located in the Professional Services Fee Schedule, available at www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

When using modifiers:

  • Anesthesia modifiers –AA, –QK, –QX, –QY, and –QZ aren't valid for services paid by the RBRVS method.

Links: For a list of modifiers that affect payment, see Payment Policies Appendix E.

For a complete list of modifiers and descriptions, see a current CPT® or HCPCS book.

An E/M service is payable on the same day as a pain management procedure only when:

  • It is the patient’s initial visit to the provider who is performing the procedure, or
  • The E/M service is clearly separate and identifiable from the pain management procedure performed on the same day, and meets the criteria for an E/M service.

Link: For more information on using the –25 modifier, see the “All E/M services” payment policy section of the Evaluation and Management (E/M) Services chapter.

The use of E/M codes on days after the procedure is performed is subject to the global surgery policy.

Link: For more information, see the “Global surgery” payment policy section of the Surgery Services chapter.

Payment limits

Anesthesia teaching physicians

Teaching physicians may be paid at the personally performed rate when the physician is involved in the training of physician residents in:

  • A single anesthesia case, or
  • Two concurrent anesthesia cases involving residents, or
  • A single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules.

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Payment policy: Team care (Medical direction of anesthesia)

Requirements for medical direction of anesthesia

Physicians directing qualified individuals performing anesthesia must:

  • Perform a pre-anesthetic examination and evaluation, and
  • Prescribe the anesthesia plan, and
  • Participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence, and
  • Make sure any procedures in the anesthesia plan that he/she doesn’t perform are performed by a qualified individual as defined in program operating instructions, and
  • Monitor the course of anesthesia administration at frequent intervals, and
  • Remain physically present and available for immediate diagnosis and treatment of emergencies, and
  • Provide indicated postanesthesia care.

In addition, physicians directing anesthesia:

  • May direct no more than 4 anesthesia services concurrently, and
  • May not perform any other services while directing the single or concurrent services.

The physician may attend to medical emergencies and perform other limited services as allowed by Medicare instructions and still be deemed to have medically directed anesthesia procedures.

Documentation requirements for team care

Documentation requirements for team care

The physician must document in the patient’s medical record that the medical direction requirements were met. The physician doesn’t submit documentation to the insurer, but must make it available upon request.

Requirements for billing

When billing for team care situations:

  • Anesthesiologists and CRNAs must report their services on separate CMS-1500 forms using their own provider account numbers,
  • Anesthesiologists must use the appropriate modifier for medical direction or supervision (–QK or –QY),
  • CRNAs should use modifier –QX.

How to calculate payment for team care

To determine the maximum payment for team care services:

  • Calculate the maximum payment for solo physician services (see the “How to calculate anesthesia payment paid with base and time units” in the payment policy for “Base and time units payment method for anesthesia” section of this chapter),
  • The maximum payment to the physician is 50% of the maximum payment for solo physician services,
  • The maximum payment to the CRNA is 45% of the maximum payment for solo physician services (90% of the other 50% share).

Additional information: How team care policies are established

L&I follows CMS’s policy for team care (medical direction of anesthesia).


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If you’re looking for more information about… Then go here:
Administrative rules for acupuncture services non-coverage Washington Administrative Code (WAC) 296-20-03002:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-03002

Administrative rules for anesthesia Washington Administrative Code (WAC) 296-220:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20
Administrative rules for licensed nursing Washington Administrative Code (WAC) 296-23-240:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-240
Administrative rules for licensed nursing billing instructions Washington Administrative Code (WAC) 296-23-245:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-245
Administrative rules for treatment guidelines for injections Washington Administrative Code (WAC) 296-20-03001:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-03001
Anesthesia conversion factor Washington Administrative Code (WAC) 296-20-135:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-135
Becoming an L&I Provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Billing code modifiers Payment Policies Appendix E:
Modifiers That Affect Payment
Noncovered procedures Payment Policies Appendix F:
Noncovered Codes and Modifiers
Payment policies for billing for medications Chapter 15:
Medication Administration and Injections
Payment policies for global surgery Chapter 29:
Surgery Services
Payment policies for using billing code modifier –25 Chapter 10:
Evaluation and Management (E/M) Services
Professional Services Fee Schedules L&I’s website:
http://feeschedules.Lni.wa.gov

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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