Wednesday, August 11, 2010

Medicaid anesthesia coverage services

COVERAGE POLICIES - WV Medicaid

WV Medicaid applies the following policies for coverage and reimbursement of anesthesia services:

• Payment for multiple anesthesia procedures is based on the procedure with the highest base unit
value and the actual anesthesia time of the multiple procedures. Only one zero code may be
billed (the highest value). Exception: Procedures performed at the same time as a delivery are
included in the maternity service and must be billed with the maternity anesthesia CPT codes
listed.

• Anesthesia time begins when the CRNA or anesthesiologist begins to prepare the member for
anesthesia care in the operating room or an equivalent area, and ends when the CRNA or the
anesthesiologist is no longer in personal attendance.

• Preoperative evaluations for anesthesia are included in the fee for the administration of
anesthesia and may not be billed as an E&M service.

• Regional IV anesthesia (e.g., 01995) is not based on time units; the base unit is covered.
Therefore, only one unit of service may be billed. CPT 01995 is used only in situations involving
the application of a tourniquet to a limb and injection of an agent for regional anesthesia.

• CPT surgical procedure codes (e.g., 62311 and 62319) are used for regional anesthesia. No
base units or time units of anesthesia may be billed. Instead, one unit of service (an injection) is
billed.

• Epidural for pain management other than the three stages of delivery (labor, delivery, and
postpartum) must be billed with CPT 62311 and 62319. Time units may not be billed.

• CPT 01996 (Daily Management of Epidural or Subarachnoid Drug Administration) is not payable
on the same day as the insertion of an epidural catheter or a general anesthesia service. The
service unit for this procedure is one base unit.

• Epidural anesthesia for surgical procedures must be billed with the appropriate “0” anesthesia
code with time units.

• Medications for pain relief given during the time of the epidural anesthesia are inclusive and must
not be billed as a separate procedure.

• Local anesthesia and IV (conscious) sedation are bundled into the procedure being provided and
must not be billed as separate services.

• Anesthesia services rendered during a hysterectomy or sterilization require completion,
submission, and acceptance of the appropriate acknowledge/consent forms.

• Occasionally a procedure which is usually requires no anesthesia or local anesthesia, because of
unusual circumstances, must be rendered under general anesthesia. A written description of the
reason for using modifier 23 is required, and the claim will be sent for review.

• Modifiers defining the CRNA or anesthesiologist participation are used in processing to allocate
payments. (e.g., AD,QK,QX,QY, and QZ) The supervising/medical directing anesthesiologist/
CRNA must bill the same procedure code.

• Physical status modifiers are not used for processing by WV Medicaid. The billing of additional
base units for physical status is prohibited.

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