1. Provided by Coventry Health Care®  ©2010 Coventry Health Care. All rights reserved.  Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Pennsylvania Medical Bill Reviewer Training Program Unit 1: Professional Services Module 2: Anesthesia

2. PA Regulations TrainingMarch 2010 Overview Part I: Anesthesia  Anesthesia Guidelines  Reimbursement of Anesthesia Services  Physical Status Modifiers  Supervision of CRNAs  Pain Management 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

3. PA Regulations TrainingMarch 2010 What is Anesthesiology? Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain. Anesthesia includes the use of:  Sedative drugs  Analgesic drugs  Hypnotic drugs  Anti-emetic drugs  Respiratory drugs  Cardiovascular drugs Anesthesia also involves:  Preoperative assessment  Intra-operative patient management  Postoperative care  Autonomic, neuromuscular, cardiac, and respiratory physiology

4. PA Regulations TrainingMarch 2010 Anesthesia Guidelines 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. 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. For example, CPT 01382 is used for anesthesia services for any arthroscopic procedure on the knee joint.

5. PA Regulations TrainingMarch 2010 Anesthesia Services Anesthesiologists may bill for a variety of services and methods of anesthesia. Anesthesia Methods:  General anesthesia  Moderate sedation  Regional anesthetic Anesthesia services include:  Pre-operative visit with the patient.  Ordering and giving medication.  Monitoring the patient’s vital signs and level of sedation.

6. PA Regulations TrainingMarch 2010 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. PA Regulations TrainingMarch 2010 Separately Reimbursable Procedures In contrast, anesthesiologists can bill for invasive procedures. Some of these invasive procedures include:  Insertion of a central venous catheter  Esophageal catheter  Swan-Ganz catheter

8. PA Regulations TrainingMarch 2010 Anesthesia Reimbursement Anesthesiologists are reimbursed per a base unit value assigned to each anesthesia code and by units of time. 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. Anesthesia Conversion Factor (PA) Example: 45 minutes of anesthesia is keyed as 45 in the unit field and the system converts that information into the appropriate payment.

9. PA Regulations TrainingMarch 2010 Modifiers Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services  Supervision of CRNAs  Pain Management Now that you are familiar with the basics of anesthesia, let’s discuss how extreme circumstances can alter reimbursement.  Physical Status Modifiers

10. PA Regulations TrainingMarch 2010 Physical Status Modifiers Anesthesia complicated by the patient’s condition may be additionally reimbursed if documentation supports the presence of significant disease. 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. PA Regulations TrainingMarch 2010 Physical Status Modifiers The physical status modifiers and their values are: ModifierDescriptionUnit P1normal, healthy patient 0 P2patient with mild systemic disease 0 P3patient with severe systemic disease 1 P4patient with severe systemic disease that is a constant threat to life 2 P5moribund patient not expected to live without the surgery 3 P6brain dead patient for harvesting 0

12. PA Regulations TrainingMarch 2010 Physical Status Modifiers Some providers will attach a physical status modifier to all anesthesia services, while others will only attach those with unit values greater than zero. Either method is acceptable and the system is automated to pay the modifier. It is the processor’s responsibility to verify that documentation justifies the addition of the payable modifiers.

13. PA Regulations TrainingMarch 2010 Certified Registered Nurse Anesthetists Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, often under the supervision of an anesthesiologist. 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. PA Regulations TrainingMarch 2010 Certified Registered Nurse Anesthetists *Both the anesthesiologist and the CRNA are reimbursed* Without supervision: the modifier –QX is applied and full payment is made at fee schedule rates. With supervision: standard fee calculation is performed: 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 –QZ.

15. PA Regulations TrainingMarch 2010 Certified Registered Nurse Anesthetists QX QY QZ Recap of Modifiers CRNA without supervision Anesthesiologist supervision of CRNA Supervised CRNA

16. PA Regulations TrainingMarch 2010 Pain Management Part II: Pain Management Services  Post-operative Pain Control  Chronic Pain Control 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

17. PA Regulations TrainingMarch 2010 Pain Management Services Pain management occurs in two distinct circumstances: Let’s take a look… Post-operative Pain Control Chronic Pain Control

18. PA Regulations TrainingMarch 2010 Pain Management Services 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. 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. PA Regulations TrainingMarch 2010 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. PA Regulations TrainingMarch 2010 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. The anesthesiologist will code her services with 01382 for basic value and time but will not bill separately for the epidural insertion. Post-operative Pain Control Example 1Example 2 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 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 catheter insertion is separately reimbursed 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. PA Regulations TrainingMarch 2010 Post-operative Pain Control In this case, it is part of the global surgery package. 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. PA Regulations TrainingMarch 2010 Chronic Pain Control 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 However, the most common treatment is injection.

23. PA Regulations TrainingMarch 2010 Chronic Pain Control Like any other specialty who performs these services, these injections are billed and reimbursed as Type of Service (TOS) 2, which is surgery. 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. PA Regulations TrainingMarch 2010 Chronic Pain Control 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. 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. PA Regulations TrainingMarch 2010 Chronic Pain Control Unfortunately, all the above scenarios are viable possibilities. 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 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.

26. PA Regulations TrainingMarch 2010 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. PA Regulations TrainingMarch 2010 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. Left hip: 20610 x 100% of FS value Right hip: 20610 x 50% of FS value Right knee: 20610 x 50% of FS value 3 Injections

28. PA Regulations TrainingMarch 2010 Chronic Pain Control 3 Time Units 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. 1 injection Billed: 20610, TOS 7, Units: 3 Paid: 20610 x 100% of FS value TOS 2, Units: 1

29. PA Regulations TrainingMarch 2010 Chronic Pain Control 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. Example: 62278 lumbar epidural: 100% FS 64440 injection paravertebral nerve: 50% FS 20550 trigger point injection: 50% FS

30. PA Regulations TrainingMarch 2010 Pain Management Services A common error in pain management occurs when providers bill for an E & M service each time the patient comes in for an injection. 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. 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.

31. PA Regulations TrainingMarch 2010 Summary Anesthesia: Services and Procedures Modifiers: How physical status modifiers affect reimbursement. How to calculate anesthesia reimbursements. How post-operative pain control services are reimbursed. How chronic pain control services are reimbursed.