Sunday, June 13, 2010

Anesthesia services - Reimbursement - Worker compensation

Reimbursement for anesthesia services shall be made to a physician or certified registered nurse anesthetist (CRNA).

1. Reimbursement shall be based on application of the following values, physical status modifiers and certain qualifying circumstances.
a. Basic value (BV) or base unit.

(1) The usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) are included in the basic value.
(2) When multiple surgical procedures are performed during an operative session, the basic value for the anesthesia procedure with the highest value is billed and reimbursed.
(3) The basic value units, listed in Section X. under Anesthesia, for each anesthesia procedure code, are used in calculating reimbursement.

b. Time (TM) units.
(1) Anesthesia time begins when the provider starts to prepare the injured employee for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance.
(2) Anesthesia time shall be billed as the total number of minutes of anesthesia. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as seventy-five (75) minutes of anesthesia.
(3) The minutes of anesthesia must be converted into time (TM) units as follows:
(a) For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) unit of anesthesia and each minute over a unit has a value of one-tenth (1/10) unit.
(b) For CRNAs, each fifteen (15) minutes of anesthesia time equals one (1) minute over a unit has a value of one-fifteenth (1/15) unit.
(c) For codes providing BV + TM, time units shall be calculated and added to the listed BV to determine the reimbursement for the anesthesia services.
(d) Only the BV units apply for codes without a time unit (TM) after the base unit.
For some anesthesia services, time is not reported additionally. Therefore,
additional units of time are not calculated for these codes when determining

c. Physical status modifiers.
(1) Anesthesia services shall warrant additional reimbursement for units based upon the injured employee’s condition and the complexity of the anesthesia service provided.
(2) A physical status modifier shall be determined to rank the injured employee’s condition.
Additional reimbursement shall be based on the unit value for the specific
physical status modifier (see Section IX. A.2.a. (5).
Physical Status Unit  Modifiers Values
P1 A normal healthy patient 0
P2 A patient with mild systemic disease 0
P3 A patient with severe systemic disease 1
P4 A patient with severe systemic disease that is a constant threat to life 2
P5 A moribund patient who is not expected to survive without the operation 3
P6 A declared brain-dead patient whose organs are being removed for donor purposes 0

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