Tuesday, November 15, 2016

CPT code 00640, 01935, 01936 and 01991, 01992

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.



Coding

The five character codes included in the Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines are obtained from Current Procedural Terminology (CPT®) copyright 2012 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physician.

The responsibility for the content of Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines is with Blue Cross and Blue Shield of Louisiana and no endorsement by the AMA is intended or should be implied.

The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Any use of CPT outside of Blue Cross Blue Shield of Louisiana Medical Policy Coverage Guidelines should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms.Applicable FARS/DFARS apply.

CPT is a registered trademark of the American Medical Association. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

CPT   - 00640, 22505, 23655, 24300, 27275
HCPCS - No codes
ICD-9 - Diagnosis All diagnoses
ICD-9 - Procedure No codes

MEDICAL POLICY AND/OR PROCEDURE

7.01.084 Spinal Manipulation Under Anesthesia

ACTIONS, COMMENTS AND REPORTING GUIDELINES

Under Policy Guidelines, added updated 2014 rationale statement. Report service with Category I CPT® codes 00640 and 22505.

CPT codes not covered for indications listed in the CPB:

00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine

Policy Guideline

A pre-anesthesia evaluation by the anesthesiologist when surgery is canceled may be covered at the level of care rendered (e.g., brief or limited visit) as a hospital or office visit. A pre-anesthesia evaluation by the anesthesiologist when the procedure is delayed is not eligible for coverage as a separate procedure. It is an integral part of the subsequent anesthesia services.

If anesthesiologists are in a group practice, one physician member may provide the preanesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. The medical record must indicate the services furnished and identify the physicians who furnished them. However, only one member of the group is eligible to bill for the entire anesthesia service.

If an organ or tissue transplant is eligible for payment, the anesthesia services for harvesting the organ or tissue from a cadaver donor is also covered (maintaining respiration, oxygenation, etc.). Harvesting of organs or tissue requires careful maintenance of the donors to retain organ viability. However, only base relative value and time units are only allowed, with no additional modifying units.

Standby anesthesia services are not eligible for payment even when required by the facility in which the patient is to have surgery.

When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure should be reported. The time reported is the combined total for all procedures.

If circumstances warrant two anesthesiologists, documentation should be submitted with the claim. A base value of five units plus time will be allowed for the second anesthesiologist.


The following revised/reactivated 2016 CPT/HCPCS codes require prior approval, or for New England Health Plan members a referral authorization, beginning with services on January 1, 2016:

95972 S3870 00635 01935 01936 01991 01992 0200T 0201T 20974 22840 22851 E0747 E0748


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”.


• Codes are listed from head to toe (00100-01860)

– Modifiers are imperative to identify anesthesia provider(s) and type

• Anesthesia for Radiological Procedures (01916-01936)

– Cardiac cath (01920), interventional radiology (01924-01926), percutaneous image guided spinal procedures (01935-01936)

• Anesthesia for Burn Excisions and Debridement (01951-01953)

– Must be familiar with Total Body Surface Area (TBSA) measurements
– Less than 4% - 01951
– Between 4%-9% - 01952
– Each additional 9% (or part thereof) - +01953

• Anesthesia for Obstetrics (01958-01969)

– Read carefully to select accurate code (vaginal, C-section, hysterectomy, abortion, etc.)

Policy: American Society of Anesthesiologist (ASA) codes

Blue Cross accepts the CPT (ASA), 00100-01999 codes, for anesthesia services billed on the 837P claim format. Blue Cross does not accept, thus will deny, surgical codes submitted with anesthesia modifiers. All services for the same operative session should be submitted on the same claim.

ASA codes are restricted to anesthesiologists and CRNAs.

Time Designation/Submission

Anesthesia time should be indicated on the 837P claim format in the unit(s) field of the 837P record. Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for the induction of anesthesia in the operating room, or an equivalent area, and ends when they are no longer in personal attendance. Anesthesia time should be coded as minutes in the units of service field. (One unit equals one minute.)

Modifier use

Modifiers are required to identify the practitioner (anesthesiologist or CRNA), the circumstance (full or part-time), medical direction and if appropriate, patient physical status.

The HCPCS full or part-time modifiers (AA, AD, QK, QS, QX, QZ and QY) should be listed in the first modifier position. The anesthesia modifiers should only be reported with the CPT anesthesia codes 00100-01999. Other services (such as nerve blocks), may be performed by an anesthesiologist or CRNA, but should not be submitted with an anesthesia modifier.

Full-time:

• Use modifier AA for full-time physician (anesthesiologist) services.
• Modifier QZ would be used for full-time CRNA services. Part-time:
• Use modifier -AD or -QK for the medical direction provided by a physician (part-time services).
• Use modifier -QY for part-time medical direction of one CRNA by an anesthesiologist.
• Use modifier -QX for medically directed CRNA services (part time).
• Modifier -QS would be used for part-time monitored anesthesia care.

Physical Status

Six levels are currently recognized for patient physical status that may be used to distinguish various levels of complexity of the anesthesia service provided. These modifiers are reported in the second modifier position, on the same line as the anesthesia service code. Additional reimbursement may be made based on the patient physical status.

Qualifying Circumstances

In accordance with CPT, the following circumstances are recognized for submission of risk. These codes must be billed on a separate line from the anesthesia service. However, qualifying circumstance codes billed without an ASA service on the same claim will be rejected. The corresponding eligible base units that may be allowed are listed below.

Anesthesia risk factors will be priced independently of the anesthesia line for easier posting of payments to accounts and greater accuracy of payments.

Anesthesia Reporting for Multiple Surgery

Code anesthesia services associated with multiple or bilateral surgical procedures performed during the same operative session with the single anesthesia code that has the highest base unit value. If multiple ASA codes are submitted for the same operative session, the lower valued ASA code(s) will be denied.

Monitored Anesthesia Care

Monitored anesthesia care (MAC) refers to instances in which an anesthesiologist has been called on to provide specific anesthesia services to a particular patient undergoing a planned procedure. In this case, the physician performs a preanesthetic examination, is physically present in the operating suite, monitors the patient’s condition, makes medical judgments regarding the patient’s anesthesia needs, and is prepared to furnish anesthesia service as necessary.

For those circumstances under which such care is medically necessary and requested by the performing surgeon, Blue Cross will allow submission for MAC the same as for any other anesthesia service.

Use modifier -QS for monitored anesthesia services

Radiology Anesthesia services - Includes CPT codes 01916 - 01936


Issues

1. Is CPT Code 01992 the appropriate anesthesia code for the disputed services?

2. What is the total allowable for the disputed services ?

3. Is the requestor entitled to reimbursement ?

Findings

1. The insurance carrier denied CPT Code 01992 based on incorrect coding and substantiates this in their position statement claiming that this code is “anesthesia block in the prone position.” CPT Code 01992 is correctly defined as “Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position” [emphasis added]. Review of the submitted documentation finds that the primary procedure, performed by a different health care provider, was placement of therapeutic spinal cord electrode arrays, which is accomplished via injection. Therefore, CPT Code 01992 is found to be the appropriate anesthesia code for the disputed services.

2. 28 Texas Administrative Code §134.203(b)(1) states, in pertinent part, “for coding, billing reporting, and reimbursement of professional medical services, Texas Workers’ Compensation system participants shall apply the following: (1) Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; … and other payment policies in effect on the date a service is provided…” Chapter 12 of the Medicare Claims Processing Manual 140.3 (effective 1/1/13) states,

“For services furnished on or after January 1, 1996, the fee schedule for anesthesia services furnished by qualified nonphysician anesthetists is the least of 80 percent of:

* The actual charge;

* The applicable locality anesthesia conversion factor multiplied by the sum of allowable base and time units.”

The base unit reported by Medicare for 2014 is 5. The requestor reported 38 minutes of monitored anesthesia time. Chapter 12 of the Medicare Claims Processing Manual 50(G) states, “For anesthesia services furnished on or after January 1, 1994, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place.” 38 minutes divided by 15 minutes, rounded to one decimal place is 2.5 time units. 28 Texas Administrative Code §134.203 (c) defines the conversion factor to be used in place of the Medicare conversion factor. The Division of Workers’ Compensation conversion factor for anesthesia with dates of service 1/1/14-12/31/14, as reported by the commissioner, is $55.75.

Base units (5) added to time units (2.5) then multiplied by the conversion factor ($55.75) equals $418.13. As the services were provided by a qualified nonphysician anesthetist (CRNA), the total allowable is calculated at 80 %, which is $334.51

3. Because the insurance carrier’s denial reasons were not supported, the requestor is entitled to reimbursement. The requestor is seeking reimbursement of $800.00. The total allowable is $334.51. Therefore, the recommended amount is $334.51.

Conclusion

For the reasons stated above, the Division finds that the requestor has established that additional reimbursement is due. As a result, the amount ordered is $334.51.


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