1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 16 ANESTHESIA

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Anesthesiologist Doctor of medicine specialized in anesthesia Usually independent practices (not hospital employees) –e.g., Anesthesia Associates, Inc. or Pain Clinic, Ltd. Services reported separately

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Uses of Anesthesia Relieve pain Manage –Unconscious patients –Life functions –Resuscitation

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Methods of Anesthesia Figure: 16.1A Endotracheal: Through mouth (Cont’d …)

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Methods of Anesthesia Figure: 16.2 Local : Application to area (injection or topical) (Cont’d …)

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Methods of Anesthesia (…Cont’d) Epidural: Into epidural space Regional: Field or nerve –Includes spinal and epidural

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Patient-Controlled Analgesia (PCA) Patient administers drug Often used to control acute post-op or chronic pain

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Moderate ( _________ ) Sedation Patient controls his/her airway and can respond to verbal commands General renders the patient unconscious Decreased level of consciousness Report with 99143 -99150 (Medicine) Codes divided on: –Age > or < 5 –Time –Provided by physician performing service (99143- 99145) or other physician (99148-99150) Conscious

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Anesthesia Section Format Figure: 16.4 Anatomic divisions

10. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Anesthesia Formula B + T + M 1. Base units 2. Time units 3. Modifying units

11. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 B is for Base Unit Published in RVG (Relative Value Guide™) by ASA National unit values for anesthesia services –Based on complexity –Base Unit Value (BUV)

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Relative Value Guide™ (RVG) Lists all CPT anesthesia codes Italicized comments added to ASA’s RVG (Cont’d…)

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Relative Value Guide Figure: 16.8 Base Unit Values assigned to each code Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (Cont’d …)

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Relative Value Guide (…Cont’d) Anesthesia services paid on set amount per unit (conversion factor) Example: Medicare unit value, North Carolina in 2011 was $20.31

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 T is for Time Patient record indicates time, e.g., 15, 30, 60 minutes Often, 15 minutes = 1 unit 60 minutes = 4 units (Cont’d…)

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 T is for Time (…Cont’d) Begins: Anesthesiologist begins to manage patient in the operating room—preop Continues throughout procedure—intraop Ends: Patient no longer under care of anesthesiologist— postop Example: Anesthesia time started at 9 AM and the patient discharged to PACU at 1:30 PM would be 270 minutes. PACU = Post-Anesthesia Care Unit

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 M is for Modifying Unit Physical condition indicated by physical status modifier P1 – P6, in Anesthesia Guidelines Risk Factor Not reported for Medicare (Cont’d …)

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Physical Status Modifiers, P1 through P6 (…Cont’d) P1 Normal, healthy P2 Mild systemic disease P3 Severe systemic disease P4 Severe systemic disease and in constant threat to life P5 Not expected to survive without operation P6 Brain dead (Cont’d…)

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Physical Status Modifiers (…Cont’d) Payment differential based on some physical status ratings

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Another Modifying Unit Qualifying Circumstances, 99100–99140 In Anesthesia Guidelines Also in Medicine section Not reported for Medicare

21. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Qualifying Circumstances Codes and Relative Value Figure: 16.10 Listed in addition to primary anesthesia code Excerpted from 2011 Relative Value Guide, © 2010 of the American Society of Anesthesiologists. All Rights Reserved. Relative Value Guide is a registered trademark of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 520 N. Northwest Highway, Park Ridge, IL, 60068-2573.

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Summation of Formula Base units (from RVG) based on CPT codes Time units (often, 15 min. = unit) Modifiers [Qualifying Circumstances (99100– 99140) and/or Physical Status (P1-P6)] B+T+M=Total Units × $ (CF) = payment –CF = Conversion factor

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Conversion Factors Figure: 16.13 CMS Anesthesia Conversion Factors

24. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Anesthesia for Multiple Surgical Procedures Once anesthetized, length of time not number of procedures (Cont’d …)

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Multiple Service (…Cont’d) Example: two procedures during same session –One, 10 base unit value; the other, 5 base unit value –Report only 10 base unit value

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 HCPCS Modifiers Added to anesthesia code -AA = Anesthesia by Anesthesiologist -AD Physician, medical supervision, 4+ concurrent procedures -G8 MAC (monitored anesthesia care), complex procedures -G9 MAC, patient history of severe cardiopulmonary condition -QK Qualified individual, medical direction of 2, 3, 4 concurrent cases -QS MAC -QX CRNA, directed by physician -QY MAC, anesthesiologist directing one CRNA -QZ CRNA, without direction

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Conclusion CHAPTER 16 ANESTHESIA