Sunday, August 28, 2016

Modifier question on anethesia claims?

Q. What defines medical direction?

For each anesthesia procedure, the anesthesiologist must perform all of the following seven services and they must be recorded in the anesthesia record:
1. Perform a pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthsia plan including, if
applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed
by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain physically present and available for immediate diagnosis and treatment of
emergencies; and
7. Provide all the indicated post-anesthesia care.

Q. What will happen if the modifiers are not on the claims?
These edits will be specific to the provider’s specialty, and claims that do not contain the appropriate modifiers or have inappropriate modifier combinations will be returned to the provider for correction.

Q. What are the specialty and modifier requirements?

• Anesthesiologist:
AA - Anesthesia services performed personally by the anesthesiologist
AD - Medical supervision of five or more concurrent anesthesia procedures by an anesthesiologist
QK - Medical direction (by anesthesiologist) of two, three or four concurrent procedures
QY - Medical direction of one CRNA/AA by an anesthesiologist
• CRNA/AA:
QX - CRNA/AA service with medical direction by an anesthesiologist
• CRNA:
QZ - CRNA service without medical direction by an anesthesiologist

Wednesday, August 24, 2016

Anesthesia add on code 99100, 99116, 99135 and 99140

Not reimbursed separately but should be billed when appropriate 

99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70
99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia
99135 – Anesthesia Complicated By Utilization of Controlled Hypotension
99140 – Anesthesia Complicated By Emergency Conditions


Non-reimbursable Services

Services billed by anesthesia assistants
Services provided by students

CRNA services performed by salaried facility employees

 Post-operative pain management on the same day as surgical procedure
 Anesthesia by the operating surgeon
 Anesthesia stand by
 Anesthesia for procedures not designated as requiring anesthesia
 Anesthesia for non-covered surgical procedures

Physical Status Modifiers

No additional reimbursement will be made when these modifiers are billed but should be submitted when appropriate

P1 Normal healthy patient
P2 Patient with mild systemic disease
P3 Patient with severe systemic disease
P4 Patient with severe systemic disease that is a constant threat to life
P5 Moribund patient who is not expected to survive without the operation
P6 Declared brain-dead patient whose organs are being removed for donor
purposes

Friday, August 19, 2016

Anesthesia and CRNA billing question?

Q. Why has Blue Cross made a decision to contract with CRNAs and AAs?
Healthcare Reform Provider Non-discrimination PPACA § 1201; PHSA § 2706(a) NON-DISCRIMINATION IN HEALTH CARE requires that group health plans and health insurers shall not discriminate against health care providers acting within the scope of their license or certification under the laws of the state of Alabama. In order to be in compliance, Blue Cross reviewed all provider types to ensure that providers covered under this provision could file claims. Changes were necessary for CRNAs and AAs.

Q. If a CRNA is already enrolled with Blue Cross, does he or she need to reapply for the CRNA Network?
Yes, having a provider number and being “credentialed” for the networks are not the same thing. All providers applying for network participation with any network must go through the same process.

Q. What is required to apply for the CRNA Network?
Providers must complete the Physician Extender Application, all supporting forms, and provide the requested documentation. Missing forms or required documentation will slow down the credentialing process.

Q. Will the Federal Employee Program (FEP) CRNA Network remain in place?
Effective January 1, 2014, the new CRNA Network will replace any existing networks, including the FEP CRNA Network.

Q. Will groups exclude CRNAs as eligible providers?
No, groups will no longer exclude CRNAs as eligible providers

Q. How were the services provided by CRNAs/AAs reimbursed previously?
Blue Cross traditionally reimbursed physicians for the services provided by CRNAs/AAs under an “incident to” arrangement. Hospital-employed CRNAs/AAs were reimbursed directly by the hospital. Anesthesiologists employing a CRNA/AA were reimbursed through the physician claim and received an extra unit for the cost of employment and were paid on 15-minute time units. Anesthesiologists that used hospital-employed CRNAs did not receive an extra unit and were paid on 30-minute time units.

Q. Will the anesthesiologist employing CRNAs/AAs still receive an extra unit?
Effective for services rendered on or after January 1, 2014, employing CRNAs/AAs will not result in any extra units added to the anesthesia calculations. Time units will all be calculated based on 15-minute units.

Q. Will the anesthesiologist using hospital-employed CRNAs/AAs have 30-minute time units?
No, all anesthesia time calculations will be based on 15-minute time units.

Tuesday, August 16, 2016

BILLING Guide CPT code 00300


Anesthesia for all procedures on the integumentary system,muscles and nerves of head, neck and posterior trunt, not otherwise specified.

Anesthesia for lesion removal is usually performed by the surgeon, If because of the size of the lesion, age or mental status of the patient, or if other conditions are present, the medical necessity of an anethesiologist may be supported. Include any appropriate Icd code necessary or attach report. The appropriate modifier indicating the type of procider as well as the type of service being rendered should be appended tot he procedure code. Modifiers indicating the physical status of the patient should also be appened when required by the third party payer. Medicare does not recognize physical status modifiers.

Monitored Anesthesia Care (MAC) 

CPT code 00300 ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS

MAC provided by qualified anesthesia personnel may be reimbursed for these procedures only when one or more of the following conditions are met:

1. It qualifies for use of HCPCS modifier QS:

MAC is appropriate for:

    Combative patients
    Patients with low pain thresholds or who experience severe pain
    Situations where the surgeon anticipates the possible intra-operative expansion of a procedure
    Any condition in a Medicare eligible pediatric patient less than 12 years of age
    The patient has a physical status grade of P3 or higher noted in the medical record
    This modifier may only be submitted with anesthesia procedure codes (i.e., CPT codes 00100-01999)
    Submit HCPCS modifier QS to indicate that the anesthesia service performed as monitored anesthesia care
    This modifier is informational only. You must report actual anesthesia time on the claim
    Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier QS second


2. It qualifies for use of HCPCS modifier G8 because the procedure being performed is for access to the central venous circulation (CPT code 00532); or is deep, complex, complicated or markedly invasive, and performed on an area of the body that is very sensitive.  These areas include the face (CPT codes 00100 and 00160), neck (CPT code 00300), breast (CPT code 00400), or male genitalia (CPT code 00920).

    Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier G8 second



3. It qualifies for use of HCPCS modifier G9 because the patient has or had a severe cardiopulmonary condition and MAC is appropriate to prevent intra-operative catastrophe.

    Submit the HCPCS modifier indicating that the service was personally performed or involved medical direction or medical supervision first, and submit HCPCS modifier G9 second

Friday, August 12, 2016

Anesthesia claim payment process

Anesthesia claims are paid based on the following: 


Time units + Base unit x Anesthesia Conversion factor. Neighborhood uses the Centers for Medicare and Medicaid Services (CMS) base unit values.

· Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier) (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance

· Anesthesia Performed under Medical Direction (QK, QX and QY modifiers) [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider


Anesthesia start time is defined as the time the anesthesiologist begins the preparation of the patient. Anesthesia end time is defined as the time when the patient is placed under post-operative care. Time anesthesiologist is not in personal attendance is non-billable.

Do not submit base unit values in the total minutes or units field on a claim. Base units are automatically calculated and paid in Neighborhood reimbursement


Calculating Time Units for Anesthesia Services and Rounding

Submit 1 unit for every 15-minute interval, rounding up to the next unit for 8 to 14
minutes, rounding down for 1 to 7 minutes.

Number of Minutes Service is Provided Number of Units to Bill

7 minutes or Less Do not Bill
8 minutes to < 23 minutes 1 unit
23 minutes to < 38 minutes 2 units
38 minutes to < 53 minutes 3 units
53 minutes to < 68 minutes 4 units
68 minutes to < 83 minutes 5 units
83 minutes to < 98 minutes 6 units
98 minutes to < 113 minutes 7 units
113 minutes to < 128 minutes 8 units

Saturday, August 6, 2016

CPT Code for Spinal Anesthesia


CPT code for Anesthesia for extensiveee spine and spinal cord procedures is 00670. RVG comment : Code 00670 is appropriate only if the surgical procedure includes segmental or   non-segmental instrumentation as defined in CPT or if the procedure includes multiplle  verteebral segments (minimum three vertebral bodies with the two associated interspaces.)

00600-00670 Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670]

Spinal Anesthesia: 1) Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord. 2) Loss of sensation due to a spinal lesion.



Anesthesia for Spinal Procedures

Code Code Description Base Unit

00600 Anesthesia for procedures on cervical spine and cord; not otherwise specified 10

00604 Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position 13

00620 Anesthesia for procedures on thoracic spine and cord; not otherwise specified 10

00625 Anesthesia for procedures on thoracic spine and cord; via an anterior transthoracic approach; notutilizing 1 lung ventilation 13

00626 Anesthesia for procedures on thoracic spine and cord; via an anterior transthoracic approach; utilizing 1 lung ventilation 15

00630 Anesthesia for procedures on lumbar region; not otherwise specified 8

00670 Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures 13

STATUS J
Status J codes are anesthesia services. Reimbursement for anesthesia services is based on the anesthesia fee schedule (not the Medicare Physician Fee Schedule), and there are no RVUs or payments contained in the MPFSDB for these services.

All the Spinal anesthesia CPT codes are comes under Status J codes.

Tuesday, August 2, 2016

CPT code 99100, 99116, 99135, 99140 - Billing tips

Anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and / or risk factors.

Codes and Definitions

99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)

99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)

99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)

99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)

This code is eligible for separate reimbursement at the allowed amount. Separately in addition to code for primary anesthesia proedure. Thi code are assigned a status indicator of "B" (bundled code) on the CMS Physician Fee schedule, and are not eligible for separate reimbursement uder Medicare guidelines. As per CMS, the value for the qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes. Payment for these services is always included in payment for other services not sprcified. There are no RVUs or payment amoount for these codes and separate payment is not made.

Coding Guidelines

CPT Assistant:
“Question: What are "qualifying circumstances for anesthesia," and when are they reported? 

Answer: Codes 99100-99140 are add-on codes that include a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These circumstances would be reported as additional procedure numbers qualifying an anesthesia procedure or service. More than one code in the section may be selected, if applicable. Codes 99100-99140 are listed in the Anesthesia guidelines in the CPT codebook.” (AMA2)

Medicare Physician Fee Schedule:

Qualifying circumstances CPT codes 99100 – 99140 are assigned a status indicator of “B” (bundled code) on the CMS Physician Fee Schedule, and are not eligible for separate reimbursement under Medicare guidelines. Per CMS, the value for these qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes.


Reimbursement Guidelines

Commercial lines of business

Effective for claims processed on or after 2/25/2016, Moda Health does not separately reimburse for CPT codes 99100 – 99140. This is based on their status indicator of “B” (bundled code) on the CMS Physician Fee Schedule.

CPT codes 99100 – 99140 will deny to provider liability with denial codes:

EX: 2M0 Service/supply is considered bundled or incidental. Not eligible for separate payment. Always bundled into a related service.

CARC: 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

RARC: M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.


99100+ (Anesthesia for patient of extreme age, under 1 year and over 70 {list separately in addition to code for primary procedure}) bundles with 00326 (Anesthesia for all procedures on the larynx and tracheas in children less that 1 year of age), 00834 (Anesthesia for hernia repair in the lower abdomen (not otherwise specified, under 1 year of age) and 00836 (Anesthesia for hernia repair in the lower abdomen not otherwise specified, infants less that 37 weeks gestational age at birth and less than 50 week gestation age at time of surgery).

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