Friday, December 2, 2016

Pediatric anesthesia service CPT 99143, 99144 AND 99145

Pediatric Moderate (Conscious) Sedation

Effective January 1, 2006, Procedure  codes 99141 and 99142 were deleted and have been replaced with Procedure  codes 99143 (Moderate sedation services…provided by the same physician performing the diagnostic or therapeutic service…requiring the presence of an independent trained observer to assist in the monitoring of the patient’s…under 5 years of age, first 30 minutes intra-service time), 99144 (…age 5 years or older, first 30 minutes intra-service time), and add-on code 99145 (…each additional 15 minutes intra-service time).

• Claims for moderate sedation should be submitted hard copy indicating the medical necessity for the procedure. Documentation should also reflect pre- and post-sedation clinical evaluation of the patient.

• Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999).

• Moderate sedation is restricted to recipients from birth to age 13. (Exceptions to the age restriction will be made for children who are severely developmentally disableddocumentation attached must support this condition. No claims will be considered for recipients twenty-one years of age or older)

• Moderate sedation includes the following services (which are not to be reported/billed separately):

* *  Assessment of the patient (not included in intraservice time);

* *  Establishment of IV access and fluids to maintain patency, when performed;

* *  Administration of agent(s);

* *  Maintenance of sedation;

* *  Monitoring of oxygen saturation, heart rate and blood pressure; and

* *  Recovery (not included in intraservice time)

• Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.

• Louisiana Medicaid has adopted Procedure  guidelines for procedures that include moderate sedation as an inherent part of providing the procedure. Louisiana Medicaid does not reimburse when a second physician other than the health care professional performing the diagnostic or therapeutic service provides the sedation. Claims paid inappropriately are subject to recoupment.

Additional Anesthesia Information

• CRNAs must place the name of their supervising doctor in Item 17 of the CMS 1500 or 837P claim form.

• Anesthesia time begins when the provider begins to prepare the patient for induction and ends with the termination of the administration of anesthesia.

• Time spent in pre- or postoperative care may not be included in the total anesthesia time.

• A surgeon who performs a surgical procedure will not also be reimbursed for the administration of anesthesia for the procedure.

• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.

• Anesthesia for arteriograms, cardiac catheterizations, CT scans, angioplasties and/or MRIs should be billed with the appropriate code from the Radiological Procedures subheading in the Anesthesia section of Procedure .



• Procedure  code 00952 (Anesthesia for vaginal procedures…; hysteroscopy and/or hysterosalpingography) pends to Medical Review and must be submitted hardcopy with the anesthesia record attached.

When billed for anesthesia administered during a hysterosalpingogram, Procedure  code 58340, the documentation attached must indicate:

* *  medical necessity for anesthesia (diagnosis of mental retardation, hysteria, and/or musculoskeletal deformities
that would cause procedural difficulty) and

* *  that the hysterosalpingogram (HSG) meets the criteria for that procedure (see the Medical Review section-Billing
Information)

• Anesthesia for dental restoration should be billed under Procedure  anesthesia code 00170 with the appropriate modifier, minutes and most specific diagnosis code. Reimbursement is formula-based, with no additional payment being made for a biopsy. A provider does not have to perform a biopsy to bill this code.

• Anesthesia for multiple surgical procedures in the same anesthesia session must be billed on one claim line using the most appropriate anesthesia code with the total anesthesia time spent reported in Item 24G on the claim form.

The only secondary procedures that are not to be billed in this manner are tubal ligations and hysterectomies.

• Anesthesia claims with a total anesthesia time less than 10 minutes or greater than 224 minutes must be submitted hard copy with the appropriate anesthesia graph attached.

• Anesthesia claims for multiple but separate operative services performed on the same recipient on the same date of service must be submitted hard copy, with a cover letter indicating the above. The anesthesia graphs from the surgical procedures should be included and the claim with attachments should be submitted to Unisys at the address below.

• When anesthesia claims deny with error codes 749 (delivery billed after hysterectomy was done) or 917 (lifetime limits for this service have been exceeded), a new claim must be submitted to Unisys at the address below with a cover letter describing the situation.

Thursday, November 24, 2016

Anesthesia and CRNA Services in a Critical Access Hospital (CAH)



Payment for CRNA Pass-Through Services


If a CAH that meets the criteria for a pass-through exemption is interested in selecting the Method II option, it can choose this option for all outpatient professionals except the CRNA’s and still retain the approved CRNAs exemption for both inpatient and outpatient professional services of CRNAs. The CAH, with an approved exemption, can choose to give up its exemption for both inpatient and outpatient professional services of CRNAs in order to include its CRNA outpatient professional services along with those of all other professional services under the Method II option. By choosing to include the CRNAs under the Method II for outpatient services, it loses its CRNA pass-through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services.

All A/B MAC (A) payments for CRNA services are subject to cost settlement.

If a CAH that meets the criteria for a pass-through exemption is not interested in selecting the Method II option, the CAH can still receive the CRNA pass-through under the Standard Option (Method I). Below are the billing requirements for Method

Provider Billing Requirements for Method I

TOBs = 85X and 11X

Revenue Code 037X for CRNA technical services

Revenue Code 0964 for Professional services

HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 37X, CRNA technical service = Cost Reimbursement

Revenue Code 0964, CRNA professional service = Cost Reimbursement for both inpatient and outpatient

Deductible and coinsurance apply.

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.


 Payment for Anesthesia Services by a CRNA (Method II CAH only)


Provider Billing Requirements for Method II Receiving the CRNA Pass-Through

TOB = 85X

Revenue Code 037X = CRNA technical service

Revenue Code 0964 = CRNA professional service

HCPCS Code = for services the CRNA is legally authorized to perform in the state in which the services are furnished

Units = Anesthesia (if applicable)

Reimbursement

Revenue Code 037X, CRNA technical service = cost reimbursement

Revenue Code 0964, CRNA professional service = cost reimbursement

Deductible and coinsurance apply.

Provider Billing Requirements for Method II CRNA - Gave up Pass-Through Exemption (or never had exemption)

TOB = 85X

Revenue Code = 037X for CRNA technical service

Revenue Code = 0964 for CRNA professional service

Reimbursement - For dates of service on or after July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = based on 100 percent of the allowed amount when not medically directed or
50 percent of the allowed amount when medically directed.

Providers bill a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service on or after July 1, 2007

Identify anesthesia claims by HCPCS code range from 00100 through 01999


Non-medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15

Medically directed CRNA

(Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsurance) times 1.15

Reimbursement - For dates of service prior to July 1, 2007

Revenue Code 037X for CRNA technical service = cost reimbursement

Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of allowed amount (Use Anesthesia formula) for outpatient CRNA professional services.

Providers a “QZ” modifier for non-medically directed CRNA services. Deductible and coinsurance apply.

How to calculate payment for anesthesia claims based on the formula - For dates of service prior to July 1, 2007

Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific anesthesia conversion factor (file name below).

The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.

If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.


Base Formula

Number of minutes divided by 15, plus the base units = Sum of base units and time Sum of base units and time times the conversion factor = allowed amount


Source

Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS

Conversion Factor = File - MU00.@BF12390.MPFS.CYXX.ANES.V1023

Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass-through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.


 CAH Outpatient Services Part B Deductible and Coinsurance

Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amounts unless waived based on statute.

For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100-04, Medicare Claims Processing Manual.

Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost-sharing - no coinsurance, deductible, copayment, or any other cost-sharing.

Tuesday, November 15, 2016

CPT code 00640, 01935, 01936 and 01991

Procedure code and Description

00640 (Investigational)  ANESTHESIA FOR MANIPULATION OF THE SPINE OR FOR CLOSED PROCEDURES ON THE CERVICAL, THORACIC OR LUMBAR SPINE

01935 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; DIAGNOSTIC

01936 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; THERAPEUTIC

01991 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); OTHER THAN THE PRONE POSITION

01992 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); PRONE POSITION

Additional Information

Monitored anesthesia (as defined by CPT codes 01991, 01992, 01935 and 01936) is considered not medically necessary when provided in conjunction with all of the Epidural Injections defined in this policy. Denials for anesthesia services will be reviewed only on appeal with supportive medical necessity documentation.

For additional information relating to medical policy regarding this service, please review the CareSource Medical Policy titled “Pain Management Interventional Procedures Policy”


Anesthesia Services  Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. 


Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure code plus modifier codes. Surgery codes are not appropriate unless the anesthesiologist or Qualified Nonphysician Anesthetist is performing the surgical procedure.

An anesthesiologist, Qualified Nonphysician Anesthetist or an Anesthesia Assistant (AA) can provide anesthesia services. The anesthesiologist and the Qualified Nonphysician Anesthetist can bill separately for anesthesia services they personally perform. In cases of medical direction, both the anesthesiologist and the Qualified Nonphysician Anesthetist would bill Medicare for their component of the procedure. Each provider should use the appropriate anesthesia modifi er.

Note: If the surgery is non-covered, the anesthesia is also non-covered. Anesthesia procedure codes are organized as follows:



Area of the Body Head Neck Thorax (chest wall and shoulder girdle) Intrathoracic Spine and Spinal Cord Upper Abdomen Lower Abdomen Perineum Pelvis (except hip) Upper Leg (except knee) Knee and Popliteal Area Lower Leg (below knee, including ankle and foot) Shoulder and Axilla Upper Arm and Elbow Forearm, Wrist and Hand Radiological Procedure Burn Excisions or Debridement Obstetric

Other Procedure CPT Code Range

00100-00222

00300-00352

00400-00474

00500-00580

00600-00670

00700-00797

00800-00882

00902-00952

01112-01190

01200-01274

01320-01444

01462-01522

01610-01682

01710-01782

01810-01860

01916-01936

01951-01953

01958-01969

01990-01999


Description of Procedure or Service

Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation).

Background

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft-tissue adhesions with less force than would be required to overcome patient resistance or apprehension. 

MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to treat (reduce) fractures (e.g., vertebral, long bones) and dislocations. MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spinal region, when standard care, including manipulation, and other conservative measures have been unsuccessful. MUA of the spine has been used in various forms since the 1930s. Complications from general anesthesia and forceful long-lever, high-amplitude nonspecific manipulation procedures resulted in decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival is attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.

MUA of the spine is described as follows: after sedation is achieved, a series of mobilization, stretching, and traction procedures to the spine and lower extremities is performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area if considered necessary to address the low back pain.

The MUA takes 15–20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners  recommend performing the procedure on 3 consecutive days for best results. Care after MUA may include 4–8 weeks of active rehabilitation with manual therapy including SMT and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar
zygapophyseal and/or sacroiliac joints under fluoroscopic guidance (MUJA) and after epidural  injection of corticosteroid and local anesthetic (MUESI). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these may be referred to as medicine-assisted manipulation.

This policy does NOT address the treatment of vertebral fractures or dislocations by spinal MUA. This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.


When Spinal Anesthesia Under Anesthesia is not covered

• Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.

• Spinal manipulation and manipulation of other joints under anesthesia involving serial  treatment sessions are considered investigational.

• Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain.

Policy Guidelines

Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. Evidence is insufficient to determine whether MUA improves health outcomes.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 22505, 00640

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. 

Wednesday, November 9, 2016

CPT code 62270, 62272, 62273

Lumbar puncture Procedure code and Description

62270 T Spinal puncture, lumbar, diagnostic 0206 $373 $204

62272 T Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 0206 $373 $204

62273 T Injection, epidural, of blood or clot patch 0207 $672 $368

What is a Lumbar Puncture?

Fluoroscopy is a special form of X-ray that produces real-time video images, as opposed to pictures on film, making it possible to see internal organs and joints in motion. A lumbar puncture (also called a spinal tap) is a fluoroscopic procedure used to collect and look at the cerebrospinal fluid (CSF) surrounding the brain and spinal cord.



A lumbar puncture can help diagnose serious infections, such as

• Meningitis;
• Other disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis;
• Cancers of the brain or spinal cord.

Sometimes doctors use lumbar puncture to inject anesthetic medications or chemotherapy drugs into the cerebrospinal fluid.

Other names for a lumbar puncture (an LP):
• Spinal tap
• Spinal puncture
• Thecal puncture (thecal sac is a membrane of dura mater that surrounds the spinal cord and the cauda equina)
• Rachiocentesis (prefix “rachio-” indicating “spine”)

Other spinal punctures or punctures to obtain cerebral spinal fluid (CSF):

• Ventricular puncture (this is a puncture into a lateral ventricle of the brain)
• Cisternal puncture (this is a cervical vertebral puncture into the  cisterna at the base of the brain)


Spinal Injection Procedures that May Be Done Without Fluoroscopy Interlaminar epidural steroid injections may be performed without fluoroscopy if performed at a certified or accredited facility by a provider with privileges to perform the procedure at that facility. The provider must decide whether to use fluoroscopy based on sound medical practice. To be payable, these spinal injections must include a facility place of service code and documentation that the procedure was performed at a certified or accredited facility. Procedure  Code 62310 62311 62318 62319

Spinal Injection Procedures that Don’t Require Fluoroscopy Procedure  Code 62270 62272 62273


Anesthesia Service Codes not an all-inclusive list

Procedure  Code - 00100 to 00936, 00940 to 01999, 62273, 99100 to 99150

HCPCS Code - D9220, D9221 (D-codes only covered for oral surgery)

Anesthesia Modifiers *not an all-inclusive list. See Modifier policy for a complete list Modifiers must be billed with anesthesia procedure codes to indicate whether the procedure was personally performed, medically directed or medically supervised.

Service will deny:

* When billed without appropriate modifier for provider’s specialty

* When modifier is not billed in the appropriate modifier position.

* When billed with invalid modifier combinations. (see incorrect modifier billing  combination grid below)

* If not billed in accordance with standard coding/billing guidelines and Neighborhood’s policies



Image Guidance: 77003 Fluoroscopy Image Guidance: Guidance: 77003 Fluoroscopy Fluoroscopy * Spine and Spinal Cord: Injection, Drainage, or Aspiration Procedure  Section Guidelines

– Injection of contrast during fluoroscopic guidance and localization is an inclusive component in 62263, 62264, 66267, 62270-62273, 62280-62282, 62310- 62319.



A second issue relates to the reimbursement schedule. Most of the interventional procedures are grouped into Group II, diagnostic and therapeutic procedures with therapeutic procedures being reimbwsed at 7 5o/o of the applicable group rates of $130.00 and other diagnostic procedures at $168.00.

The following procedures are either listed in Group II C or D:

Procedure  62273 - injection, epidural, ofblood or clot patch

Procedure  62281 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, cervical or thoracic

Procedure  62282 - injection/infusion of neurolytic substance, with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Procedure  6231,0 - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or'therapeutic substances; epidural or subarachnoid; cervical or thoracic

Procedure  62311 - - injection, single, not including neurolytic substances, with or without contrast, of diagnostic or therapeutic substances; epidural or subarachnoid; lumbar, sacral (caudal)

Saturday, November 5, 2016

Billing Guide for Anesthesiology assitand and Anesthesia time

Anesthesiology Assistants

Anesthesiology Assistants are eligible for the same level of reimbursements as a CRNA who is providing anesthesia under the direction of a physician. Unlike the CRNA who can perform alone in some states  an AA must always perform their service under the direction of a physician. (See definition of Medical Direction in General Billing Guidelines for Anesthesia)

Anesthesia Units

Anesthesia should be billed in 15-minute increments. Each 15-minute increment equals 1 unit and the
number of units should be entered into field 24G. Calculation of time starts when the practitioner is
preparing the patient for anesthesia and ends when the practitioner is no longer providing anesthesia
services. It is a continuous service.

Billing Anesthesia For Multiple Surgeries

If multiple surgical procedures are being performed in the same operative session only one anesthesia
code may be submitted. Choose the code that represents the most complicated procedure (typically the service with highest CMS Relative Value Unit). An exception exists if the anesthesia performed requires the use of an add on anesthesia code in addition to the primary procedure. Example: Primary Procedure is 01967 with add-on codes 01968, 01969.

Basic

Qualified medical professionals administer anesthesia to relieve pain while at the same time monitoring and controlling the patients’ health and vital bodily functions. Anesthesiology may be performed in the hospital, and ambulatory surgical center, and a physician’s office. Anesthesiologists and anesthesiologist- led care teams provide anesthesia. These teams include non-physician providers
such as Certified Registered Nurse Anesthetists (CRNA), Anesthesiologist Assistant (AA), interns,
residents, or a combination of both who may be either medically directed or medically supervised by
an Anesthesiologist.

Anesthesia service includes:
1. Pre-anesthetic evaluation and management
2. Medical management of the patient during the procedure
3. Post-anesthetic evaluation and treatment
4. Anesthesiologist onsite direction of any non-physician who assists in the technical aspects of
anesthesia care to a patient

Sunday, October 30, 2016

Billing Exclusions For Anesthesia



A surgeon or physician may not bill for anesthesia performed at the same time he/she is performing the surgery. This includes conscious sedation codes 99143, 99144, 99145, 99148, 99149 and 99150.

Conscious sedation and local anesthetic when performed with a procedure are considered to be a part of the global surgical package and not separately payable.

CRNAs

certified Registered Nurse Anesthetists (CRNA) are master’s prepared advanced practice nurses.

CRNAs provide anesthetics to patients in every practice setting, and for every type of surgery or procedure.

CRNAs provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other qualified healthcare professionals. Anesthesia administered by a nurse anesthetist is recognized as the practice of nursing. Anesthesia administered by an anesthesiologist is recognized as the practice of medicine. Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals give anesthesia the same way.

CRNAs may either be self-employed or work for a physician or facility based practice. There are currently 33 states that do require physician supervision of a CRNA. The determination as to whether the CRNA requires supervision is based on the scope of practice and licensing requirements for the state in which they practice. (See Table 1 for state and federal specific requirements). In states where a CRNA is allowed to practice independently there still may be CRNAs who work under the supervision of an anesthesiologist  and should bill accordingly. It should be noted that CMS defers to state law regarding supervision of a CRNA though the federal requirement for Medicaid and Medicare states that a physician must supervise the CRNA

Tuesday, October 25, 2016

CPT code 69436, 69421, 69433, 69420 Tympanostomy general aneshtesia

procedure code and description

69436 -  Tympanostomy (requiring insertion of ventilating tube), general anesthesia  - average fee payment - $170 - $180

69420 Myringotomy including aspiration and/or eustachian tube inflation


69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia

69424 Ventilating tube removal requiring general anesthesia

69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia

69799 Unlisted procedure, middle ear S2225 Myringotomy, laser-assiste


Policy: A myringotomy (69420, 69421, or S2225) may be performed with or without the insertion of tympanostomy tubes. Insertion of tubes should be reported under code 69433 or 69436, as appropriate.

Removal of ventilation, myringotomy, or tympanostomy tubes (i.e., Shea or Collar button) may be paid when performed under general anesthesia (69424).

However, removal of such tubes is considered an integral part of a doctor's medical care when not performed under general anesthesia, and therefore, is not eligible as a distinct and separate service.

Mutually exclusive procedures

For example, CPT codes 69433 and 6 436 describe different types of tympanostomy requiring insertion of ventilating tube. CPT  ode 69433 describes the procedure performed with local or topical ane thesia, and CPT code 69436 describes the procedure performed with general anesthesia. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.


Bilateral Procedures: Billing Clarification

When billing for bilateral procedures performed during the same session (unless otherwise directed in CPT), providers are to use the -50 modifier (Bilateral procedure) with the appropriate CPT code and place a “1” in the units field of the claim form. The site specific modifiers ‘LT’ (Left side) or ‘RT’ (Right side) may be used on appropriate CPT codes only when services are performed on either the right OR the left side.

Providers should not use the ‘LT’ and ‘RT’ modifier on the same procedure code instead of the -50 modifier. For example, during the same session it is not appropriate to use the ‘RT’ and ‘LT’ on CPT procedure code 69436 (Tympanostomy…) when performed bilaterally.

For questions related to this clarification, please contact Molina Medicaid Solutions Provider Services at (800)-473-2783 or (225)-924-5040.

Providers will no longer be able to bill for bilateral procedures on two lines with/without the modifi er -50, or on one line with a count of two.

Example: CPT 69436 billed with a 50 modifi er on a single date of service. CPT code billed a second time for the same date of service without the modifi er 50.

 CODE DESCRIPTION RULE LINE

 69436-50 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), ALLOW ALLOW GENERAL ANESTHESIA

 69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), DISALLOW DISALLOW GENERAL ANESTHESIA

Explanation:

• Procedure code 69436 was performed bilaterally and submitt ed once with the modifi er -50.

• The second submission of procedure code 69436 with or without modifi er 50 is not recommended for separate reporting,  because the procedure code was previously billed once on the same date of service with the modifier -50.




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