Top Tips for Tiptop Anesthesia Billing

Top Tips for Tiptop Anesthesia Billing

Factor in modifiers, add-on code use, and conversion factors for proper reimbursement.

By Amy Crenshaw-Pritchett, CPC, CANPC, CASCC, CEDC, CCS, CMDP, CMPM, ICDCT-CM, ICDCT-PCS, ICDCT-CCC, C-AHI

Coding and billing for anesthesia services can be a complicated, even daunting, task. Here are four tips to help you maintain compliance.

Anesthesia and Pain Management CANPC

1.Know Your Modifiers

As a coder or biller, you should be aware of several modifiers and how to use them correctly to ensure proper claims payment.

A  Anesthesia services performed personally by an anesthesiologist [or when an anesthetist assists a physician in the care of a single patient]

Modifier AA informs the insurance company that the anesthesiologist provided care to the patient alone, and not alongside a certified registered nurse anesthetist (CRNA).

Y  Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

Modifier QY tells the insurance company that the anesthesiologist was directing at least one CRNA.

K  Medical direction of two, three, or four concurrent anesthesia procedures involving qualified
individuals

Modifier QK tells the insurance company to make adjustments for the anesthesiologist medically directing more than one case or procedure at the same time he or she is directing the CRNA on the reported case.

D  Medical supervision by a physician: more than four concurrent anesthesia procedures

Modifier AD describes a situation similar to that described by modifier QK, but with more involvement and a greater patient load.

X  CRNA service: with medical direction by a physician

In this case, the CRNA is working under an anesthesiologist.

Z  CRNA service: without medical direction by a physician

In this case, the CRNA is working without the direction of an anesthesiologist.

S  Monitored anesthesia care service [this can only be billed by a qualified non-physician anesthetist, anesthesiologist assistant, or physician]

You must alert the insurance company when monitored anesthesia care (MAC), rather than general anesthesia, is performed. MAC is included in the payment for the procedure.

8  Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical
procedure

In this scenario, MAC is given when general anesthesia was most likely used for a procedure. For example, an 86-year-old patient undergoing hip surgery may have a better chance of survival if given MAC anesthesia rather than general anesthesia.

9  Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition

Always add this modifier for patients receiving MAC who have cardiorespiratory deficits such as chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), or emphysema. You may also use the modifier for lung cancer patients who are terminally ill, or in end stages of the disease.

2.Report Qualifying Circumstances

There are several qualifying circumstances that can be submitted to the insurance company if the services are deemed reasonable and necessary. The value of the additional codes is significant, and can mean higher payment for the anesthesiologist or CRNA. For example, reimbursement for +99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) is 1 unit of anesthesia. If +99100 is left off, the physician does not receive the full reimbursement potential. Reporting of qualifying circumstances also leads to better documentation of the patient chart and improved compliance.

Example: A 3-month-old female undergoes hernia repair. For proper reimbursement, an add-on code will allow the additional 1 unit of anesthesia to the base units.

+99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)

Example: The patient undergoes removal of subdural hematoma. The physician feels it is necessary to put the patient in a complete, deliberate state of hypothermia to decrease blood flow to the region of the brain. This is an effective way to decrease the oxygen-level requirements during surgery and decrease the incidence of postoperative neurological injury after neurosurgery.

+99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)

Example: The patient undergoes clipping of an aneurysm. The physician deems it necessary, due to potential blood loss, for the patient to be placed into hypotension to decrease blood flow to the areas in which the work will be performed. This is also used in head, face, upper thorax, or hip replacement surgeries, as the need for a blood transfusion is greatly reduced.

+99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)

Note: You must specify the emergency with the submission of this add-on code.

Example: A 56-year-old male falls from a ladder while cutting a tree limb. He sustains massive joint injury to his elbow that is now cutting off the blood supply to his lower arm. The emergency department (ED) physician deems it necessary for the patient to undergo emergency surgery to put the joint back into place and restore blood flow to the region.

Example: A 33-year-old male is playing with his son, throwing a football in the living room. The patient falls through a plate glass door, causing a severe laceration of the brachial artery in his left arm. Upon arrival to the ED, the patient undergoes emergency surgery to repair the artery to prevent loss of limb.

3.Append Physical Status Modifiers

Physical status modifiers are used for reporting the overall physical health of a patient at the time of a procedure or encounter, and can have a positive effect on the profitability of your facility.

1 A normal healthy person (units = 0)

2 A patient with mild systemic disease (units = 0)

3 A patient with severe systemic disease (units = 1)

4 A patient with severe systemic disease that is a constant threat to life (units = 2)

5 A moribund patient who is not expected to survive without the operation
(units = 3)

6 A declared brain-dead patient whose organs are being removed for donor
purposes (units = 0)

All insurers (except Medicare) allow physical status modifiers to receive additional total units of anesthesia reported for patients with higher risk factors or chronic conditions.

Example: A patient has uncontrolled diabetes mellitus, COPD, CHF, and chronic kidney disease (CKD) stage III. This patient would be classified as a P3 due to the severe systemic disease processes.

Example: A patient was involved in a motor-vehicle accident and is pronounced dead on arrival. The patient is an organ donor, and is taken to the operating room for organ harvesting. This patient would be classified as a P6.

Example: A patient has hypertension and undergoes a hiatal hernia repair. This patient would be classified as a P2 because the hypertension is not classified as uncontrolled.

4.Properly Calculate Time for Anesthesia Services

An additional factor of coding and billing for anesthesia services is the calculation of base units and the use of conversion rates for total anesthesia time. Base units are the numeric value that Medicare has attached to the anesthesia CPT® codes for anesthesia services. For example, 00560 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest, without pump oxygenator carries a weight value of 15 base units.

For commercial insurance companies, the following formula is used to report time units for provided anesthesia:

Base Units + Time + Physical Status Modifier = Total Units

For Medicare, the following formula is used to report time units for anesthesia provided:

Base Units + Time = Total Units

Anesthesia is calculated at 15-minute intervals (15 x 4 = 60). When a case runs over seven minutes, guidelines state to round up to the next 15 minutes provided. For example, if anesthesia started at
9:00 a.m. and ended at 10:07 a.m., round up to the 15 minutes (10:15 a.m., for a total of five units); do not round down to 10:00 a.m.

Example: Anesthesia provided for the exploration of the pericardial sac. Anesthesia began at 9:00 a.m. and ended at promptly 10:15 a.m. The patient has been classified as a P3 due to severe hypertension and diabetes mellitus. In this case, the total units are calculated:

Base Units (15) + Time (5) + Physical Status Modifier (1) = 21 Total Units of Billable Anesthesia

It’s important to stay current on the conversion factor for your state. Each year, the Centers for Medicare & Medicaid Services updates the conversion factor rate for each state.

Now that you have found your total units, you can calculate your expected reimbursement. Continuing with our example, above, and using the conversion rate for my home state of Alabama:

21 (total billable anesthesia units) x $21.43 = $450.03

Following the factors mentioned in these anesthesia tips will provide guidance to help ensure your physician and your facility receive proper reimbursement for anesthesia services provided to patients.


 

Amy Crenshaw-Pritchett, CPC, CANPC, CASCC, CEDC, CCS, CMDP, CMPM, ICDCT-CM, ICDCT-PCS, ICDCT-CCC, C-AHI, has been involved in many aspects of coding and billing for over 20 years. As an auditor/educator at HIMagine Solutions, Pritchett’s responsibilities include chart auditing, coding and compliance education, and newly hired coder education. She owns and operates a medical coding and billing company, Gulf Coast HIM Solutions. Pritchett is also the president and a recurring presenter/speaker of the Mobile, Alabama, local chapter. She is an adjunct instructor at the University of South Alabama, Medical Coding Continuing Education Department.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 423 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

4 Responses to “Top Tips for Tiptop Anesthesia Billing”

  1. Heather says:

    Renee,

    I have been hearing from a few insurance companies that CMS has discontinued the use of the physical condition modifiers as of 2015. Medicare is still paying my claims with the P1-P4 modifiers that my doctor codes, but some of the MR Risk HMO plans have been denying claims when I use those modifiers.

    Have you heard anything about those modifiers being discontinued? Where would I find information on what is replacing them? How are providers going to get reimbursed for more complicated procedures? Any information you have on the subject would be very appreciated.

    Heather

  2. Sharon Trader says:

    “Anesthesia is calculated at 15-minute intervals (15 x 4 = 60). When a case runs over seven minutes, guidelines state to round up to the next 15 minutes provided. For example, if anesthesia started at
    9:00 a.m. and ended at 10:07 a.m., round up to the 15 minutes (10:15 a.m., for a total of five units); do not round down to 10:00 a.m.”
    Please provide a link to the guidelines cited here. My review of the CMS IOM states: Actual anesthesia time in minutes is reported on the claim. 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. The A/B MAC does not recognize time units for CPT codes 01995 or 01996. From: Medicare Claims Processing Manual Chapter 12 Physicians & Non-Physician Practitioners Section 50.G
    This leads me to understand that units are not billed on Medicare claims. Please state your position on this.

  3. Carol Self says:

    Good afternoon, I am new to a very large anes group and in sitting with charge entry find that they are billing the start time of anes for the Anes as 1 minute after the start time for the CRNA. They say this is a CMS requirement. I cannot find that guideline. Can you please help??

  4. Jodi Rosenow says:

    There is some misinformation in this article. Most of the major payers – BCBS, UHC, Tricare, state Medicaid programs – have differing rules on the rounding times for anesthesia services. Some use the 7 minute rule, but if you review their manuals you will find that some allow any increment of time to increase the time units. There are several commercial payers who will not allow for extra payment for the physical status modifiers or the qualifying circumstances. There are also many differences in how to bill for OB epidurals.

    The best suggestion to understand how a claim should be billed to a particular payer is to check the guidelines on their website and/or in their provider manual.

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