Reimbursements

Category:

Anesthesia Services

Reimbursement Policy NDRP-ANES-001
Topic: Anesthesia
Effective Date: July 1, 2018
Last Reviewed:
February 20, 2019

Description:

This policy is to provide direction on The Plan’s reimbursement of anesthesia services.

Policy:

The following types of anesthesia qualify for reimbursement as anesthesia services:

  1. Inhalation
  2. Regional
    • Spinal (low spinal, saddle block)
    • Epidural (caudal)
    • Nerve block (retrobulbar, brachial plexus block, )
    • Field block
  3. Intravenous
  4. Rectal
  5. Conscious sedation

Local anesthesia, which is direct infiltration of the incision, wound, or lesion is not a covered service.

Reimbursement for anesthesia services is based on the use of relative value units, including base units, plus time units multiplied by a monetary conversion factor.  The base units as indicated by CMS will take precedence over other association’s base unit value when they may be different.

The base value for anesthesia when multiple surgical procedures are performed is the base value for the procedure with the highest unit value. Reimbursement is not allowed for the base unit value of a second, third, etc., procedure.

 Anesthesia time begins when the anesthesiologist or CRNA is first in attendance with the patient for creating the anesthetic state. Anesthesia time ends when the anesthesiologist or CRNA is no longer in personal attendance; that is, when the patient may be safely placed under customary postoperative supervision. This time must be documented on the anesthesia record, but not on the claim.

Time must be indicated on all anesthesia claims. Report the actual time spent administering anesthesia as minutes on the claim in the “days or units” block. The Plan will convert total minutes to time units. A “time unit” is a measure of each fifteen (15) minute interval or the actual time reported. Time units are calculated by dividing the total minutes of anesthesia time reported by fifteen (15), rounding to the next whole number.

Modifying Units for Anesthesia Services

Modifying units represent those circumstances that necessitate skills of a physician beyond those usually required.

Qualifying circumstances representative of age, emergency, total body hypothermia, and controlled hypotension should be reported under codes 99100, 99116, 99135 and 99140. These procedures are classified as Status B codes and are not reimbursable.

Physical Status Units

 No allowance is made by BCBSND for physical status, represented by modifiers P1-P6.

Position Units

 No allowance is made by BCBSND for position units

Anesthesia Services Prior to Postponement of Surgery

The Plan uses the following guidelines to adjudicate claims for the administration of anesthesia prior to the postponement of surgery:

  1. If surgery is cancelled because of the anesthesiologist’s preoperative appraisal, reimbursement can be made based on a (Coverage for consultations is determined according to individual or group customer benefits.)
  2. When surgery is aborted after general or regional anesthesia induction has taken place, reimbursement is made based on 3 base units plus time units multiplied by the conversion factor.
  3. If anesthesia is reported under a NOC/NOS code, the Plan will adjudicate claims for the administration of anesthesia prior to the postponement of surgery, according to policy

Modifier 73 – Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia

Note: Anesthesia billed with modifier 73 is not applicable for professional billing and will be denied.

Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump

Continuous infusion of an analgesic to operative wound sites is a technique for postoperative pain control for surgeries typically requiring oral or parenteral narcotics for pain control.

Local delivery of analgesia to operative sites is designed to reduce postoperative pain, while limiting systemic side effects of analgesia. Additional benefits include reduced need for oral narcotics, decreased incidence of breakthrough pain, and faster return to normal activities. Drug delivery can be regulated using simple disposable elastomeric pumps filled with analgesics attached to a variety of catheters that provide continuous delivery of the drug to the surgical site. Catheters may contain multiple openings so that the drug seeps into the operative wound all along its length. Elastomeric infusion pumps are designed to deliver drugs for up to five days followed by removal of the catheter. Elastomeric pumps to deliver local analgesia have been used postoperatively for the following:

  • Orthopedic procedures, such as repair of the anterior cruciate ligament
  • Urology procedures, such as prostatectomy
  • Plastic surgery procedures
  • Obstetrical/gynecologic procedures, such as cesarean section
  • Gastrointestinal surgery procedures, such as hemorrhoidectomy or gastric bypass
  • Thoracic surgery procedures, such as thoracotomy
  • Cardiovascular surgery procedures, such as sternotomy

Only elastomeric pumps and associated catheters that have received approval from the US Food and Drug Administration (FDA) are to be used.

Reimbursement for catheter insertion and removal to provide continuous delivery of a drug to a surgical site is included in the allowance for the surgery and therefore, is not eligible for separate reimbursement.

The elastomeric infusion pump (codes A4305 and A4306) is a supply most commonly reported as a facility expense. However, when reported by the doctor, coverage for the elastomeric infusion pump is determined according to individual or group customer benefits.

Monitoring Services Performed in Conjunction with the Administration of Anesthesia

The reporting of anesthesia services is appropriate by or under the responsible supervision of a physician. These services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services to afford the patient the anesthesia care deemed optimal by the anesthesiologist during any procedure.

If monitoring services are reported on the same day as anesthesia, and the charges are itemized, the Plan will combine the charges and reimburse only the anesthesia. Reimbursement for the anesthesia performed on the same date of service includes the allowance for these services and are not eligible as a separate and distinct service. A participating or network provider cannot bill the member separately for these services. If these services are performed independently, report the service with modifier 59.

Examples of monitoring procedures performed while administering anesthesia or for purposes of intraoperative anesthesia management are:

  • ECG/EKG monitoring
  • Administration of fluids and/or blood
  • Respiratory functions (i.e. oxygen saturation [oximetry], end-tidal CO2 monitoring [capnography], etc.)
  • Temperature
  • Blood Pressure
  • Mass spectrometry

Note: Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient medical record must support its use in accordance with CPT guidelines.

Direction of Anesthesia Services

The amount for physician anesthesia services is based on allowable base and time units multiplied by an anesthesia conversion factor.

Concurrent directed anesthesia procedures are defined regarding the maximum number of procedures that the physician is directing within the context of a single procedure.

Physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, directed, or supervised.

Specific anesthesia modifiers recognized by BCBSND include:

AA – Anesthesia Services performed personally by the anesthesiologist
QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QS – Monitored anesthesia care service
QX – CRNA service; with medical direction by a physician
QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist
QZ – CRNA service: without medical direction by a physician

Note: The QS modifier is for informational purposes. Providers must report actual anesthesia time on the claim.

Payment for Directed Anesthesia

Payment for the physician’s directed service is determined based on our fee schedule and the modifier that is billed on the claim. Direction occurs if the physician directs qualified individuals in one, two, three, or four concurrent cases and the physician performs the following activities:

  1. Performs a pre-anesthetic examination and evaluation;
  2. Prescribes the anesthesia plan;
  3. Personally, participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
  4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
  5. Monitors the course of anesthesia administration at frequent intervals;
  6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and
  7. Provides indicated-post-anesthesia care

Cross Reference:

NDRP-ANES-002 – Moderate (Conscious) Sedation