Pennsylvania Medical Bill Reviewer Training Program

1. Pennsylvania Medical Bill Reviewer Training Program Unit 1: Professional Services Module 2: Anesthesia

2. Overview Hi! In this module, you will learn about anesthesia services, how they are reimbursed, and the circumstances that can affect reimbursement. Then, you will learn how anesthesia services are used for pain management services. Let’s start by discussing general anesthesia guidelines and how anesthesia services are reimbursed... Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services • Physical Status Modifiers • Supervision of CRNAs • Pain Management Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services

3. What is Anesthesiology? • Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain. Anesthesia includes the use of: Anesthesia also involves: • Sedative drugs • Analgesic drugs • Hypnotic drugs • Anti-emetic drugs • Respiratory drugs • Cardiovascular drugs • Preoperative assessment • Intra-operative patient management • Postoperative care • Autonomic, neuromuscular, cardiac, and respiratory physiology

4. The anesthesia section in the CPT ranges from 00100-01999. Anesthesia codes do not correspond one-to-one with surgery codes because multiple surgery codes may crosswalk to the same anesthesia code. For example, CPT 01382 is used for anesthesia services for any arthroscopic procedure on the knee joint. Anesthesia Guidelines Therefore, 18 surgery codes correspond to this single anesthesia service. • Single anesthesia codes correspond to multiple surgical codes because the anesthesiologist performs the same tasks for any of the arthroscopic knee services and the only variation may be time.

5. Anesthesia Services • Anesthesiologists may bill for a variety of services and methods of anesthesia. Anesthesia Methods: Anesthesia services include: • General anesthesia • Moderate sedation • Regional anesthetic • Pre-operative visit with the patient. • Ordering and giving medication. • Monitoring the patient’s vital signs and level of sedation.

6. Procedures not Separately Reimbursable • Just like other procedures, some anesthesia procedures can be billed separately, while other procedures cannot be billed separately. Services not billed separately include: • Pre and post-operative routine visits. • Administration of fluids, including blood. • Usual monitoring services such as: EKG, temperature, blood pressure, oximetry, capnography, and mass spectrometry. • The system is automated to deny (edit U001) these non-invasive monitoring services billed with an anesthesia code.

7. In contrast, anesthesiologists can bill for invasive procedures. Separately Reimbursable Procedures Some of these invasive procedures include: • Insertion of a central venous catheter • Esophageal catheter • Swan-Ganz catheter

8. Anesthesiologists are reimbursed per a base unit value assigned to each anesthesia code andby units of time. Anesthesia Reimbursement Anesthesia Conversion Factor (PA) • Although PA Workers’ Compensation guidelines give anesthesia pricing as a 15-minute block, the system has it broken down to a per-minute value. • Therefore, the time is keyed into the unit field per minute. Example: 45 minutes of anesthesia is keyed as 45 in the unit field and the system converts that information into the appropriate payment.

9. Modifiers Now that you are familiar with the basics of anesthesia, let’s discuss how extreme circumstances can alter reimbursement. Part I: Anesthesia • Anesthesia Guidelines • Reimbursement of Anesthesia Services • Supervision of CRNAs • Pain Management • Physical Status Modifiers

10. Anesthesia complicated by the patient’s condition may be additionally reimbursed if documentation supports the presence of significant disease. Physical Status Modifiers • These significant complications are indicated by physical status modifiers. While hypertension and diabetes are not considered significant enough to warrant use of the higher level physical status modifiers, conditions such as: • Congestive heart failure • Emphysema • Uncontrolled epilepsy ...are reimbursable.

11. Physical Status Modifiers • The physical status modifiers and their values are:

12. Some providers will attach a physical status modifier to all anesthesia services, while others will only attach those with unit values greater than zero. It is the processor’s responsibility to verify that documentation justifies the addition of the payable modifiers. Physical Status Modifiers Either method is acceptable and the system is automated to pay the modifier.

13. Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, often under the supervision of an anesthesiologist. Certified Registered Nurse Anesthetists • To be eligible for reimbursement, the anesthesiologist must be within hearing and visual range. • The anesthesiologist must be involved in the medical direction of the patient, including pre and post-operative care.

14. Certified Registered Nurse Anesthetists Without supervision: the modifier –QZ is applied and full payment is made at fee schedule rates. With supervision: the modifier –QX is applied for standard fee calculation. Both the anesthesiologist and the CRNA are reimbursed. Base units + time + physical status modifiers x conversion factor Then, HALF the allowable reimbursement is paid to the supervising anesthesiologist with modifier –QY and HALF is paid to the CRNA with modifier –QX.

15. Certified Registered Nurse Anesthetists Recap of Modifiers QX CRNA with supervision QY Anesthesiologist supervision of one CRNA QZ CRNA without supervision

16. Pain Management Now that you are familiar with how anesthesia is generally used, let’s discuss how it can be used for pain management. Part II: Pain Management Services • Post-operative Pain Control • Chronic Pain Control Part II: Pain Management Services • Post-operative Pain Control • Chronic Pain Control

17. Pain Management Services • Pain management occurs in two distinct circumstances: Post-operative Pain Control Chronic Pain Control Let’s take a look…

18. This is because the service includes the anesthetic and all monitoring necessary to bring the patient safely through the surgery, regardless of the type of anesthetic. Pain Management Services • If a spinal, epidural, or regional anesthetic is used for anesthesia during a surgery instead of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.

19. Post-operative Pain Control Post-operative Pain Control However, if a general anesthetic is given, making the patient unconscious, and the anesthesiologist gives an epidural or regional block for post-operative pain control in addition to the anesthesia given for the surgery, it can be billed separately.

20. Post-operative Pain Control Example 1 Example 2 Bob Smith is having a meniscectomy performed in his right knee. Bob Smith is having a meniscectomy performed in his right knee. He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with an epidural anesthetic, making him numb from the waist down, and some mild IV sedation for anxiety control. He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with a general anesthetic because his anxiety level is so high. In addition, the anesthesiologist will insert an epidural catheter for pain control in the 24 hours following surgery. The anesthesiologist will code her services with 01382 for basic value and time but will not bill separately for the epidural insertion. The catheter insertion is separatelyreimbursed because it is not part of the anesthetic for the surgery. The anesthesiologist may not bill 01996 for pain control management on the day of surgery.

21. In this case, it is part of the global surgery package. Post-operative Pain Control Just like other procedures, the surgeon cannot bill separately for pain control services, such as inserting a pain pump catheter, if it is performed as part of the surgery.

22. In chronic pain management, anesthesiologists that specialize in pain control may see the patient for a single or a series of injections, either into a joint or body area, or into the epidural space. They may also employ non-injection methods of pain control such as biofeedback, physical therapy, and counseling. Chronic Pain Control Chronic Pain Control However, the most common treatment is injection.

23. Like any other specialty who performs these services, these injections are billed and reimbursed as Type of Service (TOS) 2, which is surgery. Chronic Pain Control • If these services are billed as TOS 7, which is anesthesia, the processor must change the TOS to reflect that this is a surgical service.

24. Anesthesiologists often used the American Society of Anesthesiologists (ASA) Relative Value Guide to bill for particular services. This reference guide lists the recommended base values for each procedure. Chronic Pain Control Often, anesthesiologists will mistakenly indicate the anesthesia base value in the units field on the bill. Remember, the bill review system already calculates the base value associated with a procedure.

25. Unfortunately, all the above scenarios are viable possibilities. Chronic Pain Control • As you can see, when reviewing bills, it is important to determine the type of units and verify that they coincide with the service provided. If multiple units are billed, the processor must determine if the provider has: • performed multiple injections • billed for time units • indicated the anesthesia base value of the service in the unit field

26. Chronic Pain Control Example Suppose a provider bills CPT 20610: large joint injection, for 3 units. As a processor, you should ask, “Is he billing for 3 injections or 3 time units? Or, is this the base value?" Only documentation can verify if this represents injections of both hips and one knee, for a total of 3 injections... ...or a single injection took the anesthesiologist 45 minutes, for a total of 3 time units. Let’s take a look…

27. Chronic Pain Control 3 Joint Injections: left hip, right hip, & right knee The lines are separated, and the procedures are reimbursed at multiple procedure cascade. 3 Injections Left hip: 20610 x 100% of FS value Right hip: 20610 x 50% of FS value Right knee: 20610 x 50% of FS value

28. Chronic Pain Control Single large joint injection representing time units or ASA base value The processor will need to change the unit field to 1 and the TOS to 2 to represent the actual service performed. 3 Time Units 1 injection Billed: 20610, TOS 7, Units: 3 Paid: 20610 x 100% of FS value TOS 2, Units: 1

29. If multiple types of injections are performed, they are reimbursed at multiple procedure cascade. If the provider appeals the recommendation, he is educated on multiple cascade logic, which avoids duplicating reimbursement for overhead, pre-operative, and post-operative care. Chronic Pain Control Example: 62278 lumbar epidural: 100% FS 64440 injection paravertebral nerve: 50% FS 20550 trigger point injection: 50% FS

30. A common error in pain management occurs when providers bill for an E & M service each time the patient comes in for an injection. Pain Management Services If a pattern, such as weekly visits is obvious, it is unlikely each visit was a significant, separately identifiable service and not just routine questioning about pain level. Unless the provider is assessing the patient’s progress in detail, treating an additional condition, or teaching or counseling the patient extensively, the E/M service is included in the injection procedure payment.

31. How to calculate anesthesia reimbursements. Anesthesia: Services and Procedures Modifiers: How physical status modifiers affect reimbursement. How post-operative pain control services are reimbursed. How chronic pain control services are reimbursed. Summary