Wednesday, June 29, 2016

billing anesthesia time units - calculation for personally performed and Medical direction

Anesthesia Payment & Billing Information

Time and Points Eligible Anesthesia Procedures Defined

Blue Cross and Blue Shield of Texas has determined that certain anesthesia procedures will be reimbursed on time and points methodology.

Procedures  that  are   not  included  on  the   Anesthesia  Time  &  Points Eligible List will not be reimbursed using time and points methodology. If a procedure is  not on this list, and it is submitted using anesthesia indicators for Time & Points such as:

using an anesthesia modifier, or
using time on the claim, or
if submitted on a non-HIPAA claim format, (Type of Service = 7),

then the provider may receive a denial message for that procedure noting that the service is not eligible for time and points payment methodology.

Anesthesia Services

Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or CPT surgical codes plus a  modifier.  Blue  Cross  and  Blue  Shield  of  Texas  will  require  that  the appropriate anesthesia modifier be filed on anesthesia services.

An  anesthesiologist  or  a  CRNA  can  provide  anesthesia  services.  The anesthesiologist and the CRNA can bill separately for anesthesia services personally performed. When an anesthesiologist provides medical direction to a   CRNA,   both  the  anesthesiologist  and  the  CRNA  should  bill  for  the appropriate component of the procedure performed. Each provider should use the appropriate anesthesia modifier.

In  keeping  with  the  American  Medical  Association  Current  Procedural Terminology  (CPT)  Book,  services  involving  administration  of  anesthesia include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring   services  (e.g.,  ECG,  temperature,  blood  pressure,  oximetry, capnography  and  mass  spectrometry).  Intra-arterial,  central  venous,  and Swan-Ganz catheter insertion are allowed separately.

Payment Calculation Information

Time Units : Time units will be determined by using the total time in minutes actually spent performing the procedure. Fifteen minutes is equivalent to one (1) time unit.  Time units will be rounded to the tenth. Therefore, if the procedure lasted 49 minutes, the time units in this example would be 3.26 or 3.3 time units. The units field 24G of the CMS-1500 form should reflect the number of minutes the provider spent on the procedure, (e.g. one hour-thirty minutes should be reflected as (90) in the units field).

Anesthesia time begins when the provider of services physically starts to prepare the patient for induction of anesthesia in the operating room (or equivalent) and ends  when  the provider  of  services  is  no  longer  in constant  attendance  and  the  patient  may  safely  be placed under postoperative supervision.

Base Points : The basis for determining the base points is the Relative Value Guide published by the American Society of Anesthesiologists  (ASA).  HMO  Blue  Texas  and  Blue Cross  and Blue Shield of Texas shall implement any yearly  update of the Relative Value Guide within 60 days of receipt. Base points used to process claims will be the base  points in effect on the date(s) Covered Services are  rendered. The exception to this will be Covered Services provided on dates between the receipt of  the  Relative  Value  Guide  published  by  ASA  and implementation of the updated material.Claims incurred  during  the  exception  period  will  be  priced based  on  the  Relative  Value   Guide   in  effect  on December 1st of the prior calendar year. Newly established codes will be paid at HMO Blue Texas and Blue Cross and Blue Shield of Texas  determined rates until the annual update is implemented.

Physical Status Modifiers – to be billed by anesthesiologists and/or CRNAs

P1 A normal healthy person

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

Qualifying Circumstances – to be billed by anesthesiologists and/or CRNAs

99100 Anesthesia for patients of extreme age, under 1 year and over 70 (list separately in addition to code for primary procedure)

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

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

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

Payment Calculation : Time units plus base points plus unit value(s) allocated to physical status modifiers and/or qualifying circumstances listed above (if applicable) equals “Y”. Allowable  amount  equals  the  anesthesia  conversion factor multiplied by “Y”.

Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969

When a primary OB delivery anesthesia procedure (01967) is billed with either  01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.

Ventilator Management in Conjunction with Anesthesia Services 94656 and 94657

Ventilation management billed on the same day as an anesthesia procedure is part of the global anesthesia service for the first 24 hours after anesthesia induction and therefore it is not billable.

If procedure code 94656 is reported on the same day, on the same patient, by the same provider as an anesthesia procedure, the
ventilation management service will be denied.

Subsequent ventilation management (94657) billed on the same day as an evaluation and management service is considered part of the evaluation and management service and is not payable separately even if the evaluation and management service is billed with modifier 25. If the patient develops unusual postoperative respiratory problems that require reintubation and/or ventilation management, the physician should report the service with critical care or the appropriate evaluation and management code(s).

Daily Hospital Management of Epidural or Subarachnoid Continuous Drug Administration  -  01996

Procedure code 01996 is not allowed on the day of the operative procedure. Only one (1) unit of service (not base units) will be allowed each day, starting on the first day following the surgical procedure, up to a maximum of three (3) days.

62310, 62311, 62318 and 62319

Blue Cross and Blue Shield of Texas has determined that these procedures are surgical services and claims should reflect a type of service of 2. These codes will be reimbursed at the current maximum allowable as determined by HMO Blue Texas and Blue Cross and Blue Shield of Texas.  Claims filed with CPT anesthesia procedure code 01991 or 01992 and type of service of 7 will be reimbursed on time and points methodology.

Note: The codes referenced in the information above are subject to changes made by the owner of the code set (i.e. CPT, HCPCS, Revenue Codes, etc).

Anesthesia Time and Calculation of Time Units

Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. We consider anesthesia time to begin when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

Anesthesia time must be reported in minutes. Failure to include anesthesia time may result in the claim being either returned or denied. If anesthesia time is reported in units, incorrect payment will result. Minutes will be converted to units by assigning one unit to each 15 minutes of time, or any part of a 15-minute period that anesthesia was administered (exception is Procedure 01967, which is based on a 60-minute unit). No additional time units are payable for add-on codes; therefore, total time must be reported on the primary procedure code. In the case where multiple procedures are performed, time for lower base unit value codes should be reported on the highest base unit value code. Note: We do not recognize time units for Procedure 01996 (see this section for more on Pain Management). The physician who medically directs the CRNA would ordinarily report the same time as the CRNA reports for the CRNA service.

Blue Cross/HMO Louisiana uses the following table to calculate the number of time units:

1 minute to 15 minutes = 1 unit

16 minutes to 30 minutes = 2 units

31 minutes to 45 minutes = 3 units

46 minutes to 60 minutes = 4 units

61 minutes to 75 minutes = 5 units, etc.

According to Procedure guidelines, anesthesia time begins when the anesthetists begins to prepare the  patient in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance and the patient may be safely placed under post-anesthetic supervision. Anesthesia time should be reported in minutes. Effective for dates of service on or after January 1, 2014, for all Anesthesiologists, CRNAs and AAs, one unit of time will be allowed for each 15 minute increment of anesthesia or a fraction thereof.

Reimbursement for time based anesthesia is based on the following formulas:

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

Anesthesia Performed under Medical Direction (QK, QX and QY modifiers)

[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Anesthesia “base unit” is the number of units assigned for the anesthetic management of surgical procedures using nationally recognized anesthesia base value standards. Base units are automatically calculated and should not be reported on the claim form. Blue Cross will utilize the CMS base unit values.

Anesthesia time should be submitted on the claim as total minutes. For example, one hour and nine minutes of anesthesia time is billed as 69 minutes. Blue Cross then converts minutes into 15-minute increments. This calculation would be four 15 minute time units and 9/15 of one unit. Total time units for this example are 4.6.

Blue Cross recognizes that the patient must be prepared immediately prior to induction and that some time may be spent immediately after the conclusion of the surgical procedure. Generally, no more than one unit should be necessary to prepare the patient for post-operative transfer to the recovery room. It is inappropriate to bill for anesthesia time while the patient is waiting in a holding area. If it is necessary for a more extensive service to be provided, documentation must be provided in the patient’s medical record to substantiate medical necessity. It is inappropriate to bill time units for services such as administration of blood products or antibiotics in the holding area, when such services could be provided in another area of the hospital or facility.

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