Revenue Cycle Insider

While more information is usually helpful, not all payers reimburse accordingly.

Anesthesia plays an important role in surgical and diagnostic procedures by helping manage a patient’s pain, comfort, and safety. These services may include local, general, regional, or monitored anesthesia and are provided by qualified healthcare professionals. Understanding anesthesia services is important for accurate documentation, coding, and reimbursement.

The Centers for Medicare & Medicaid Services (CMS) has particular rules and requirements for reporting services provided to beneficiaries, and commercial payer policy may vary.

Read on for more information on coding anesthesia services.

Get a Handle on Anesthesia Service Basics

Anesthesia start and stop time is calculated by the period when an anesthesia provider is present with and providing care to the patient. It begins when the practitioner starts preparing the patient for anesthesia in the operating room or a similar area and ends when anesthesia services are complete and the patient can be safely transferred to postoperative care (PACU). Anesthesia time is measured continuously from the beginning to the end of the anesthesia service, as described in the Medicare Claims Processing Manual, Chapter 12.

Medicare covers anesthesia when it is deemed medically necessary for a covered surgical or diagnostic procedure and is provided by a qualified professional. Medicare Part A covers anesthesia services in a hospital setting while Medicare Part B covers anesthesia services provided to hospital outpatients and patients undergoing procedures in a freestanding ambulatory surgical center (ASC).

There are four main types of anesthesia: general, regional, monitored sedation, and local. See the MedlinePlus anesthesia overview and the National Institute of General Medical Sciences (NIGMS) anesthesia fact sheet for descriptions of anesthesia types.

Under the CMS Anesthesia Services Condition of Participation guidance, anesthesia may only be administered by qualified providers that include anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiologist assistants (AA) working under the supervision of an anesthesiologist, physicians (MDs or DOs) and dentists, oral surgeons, or podiatrists who are qualified to administer anesthesia under state law. Standard anesthesia services include preoperative evaluations, continuous intraoperative monitoring and drug administration, and postoperative evaluations.

Know Which Codes and Modifiers Can Affect Payment

Many anesthesia medical coding services are performed during complex circumstances. Depending on the patient’s risk factors and clinical condition, you might report qualifying circumstance add-on codes in addition to the anesthesia procedure codes to accurately reflect the increased complexity and risk associated with the service and support appropriate reimbursement. You’ll choose from the following add-on codes for qualifying circumstances:

• +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70)
• +99116 (Anesthesia complicated by utilization of total body hypothermia)
• +99135 (Anesthesia complicated by utilization of controlled hypotension)
• +99140 (Anesthesia complicated by emergency conditions (specify))

Physical status modifiers are standardized codes added to anesthesia claims to show the patient’s overall health and existing medical conditions and have a value expressed in units that may affect payment calculation, depending on the payer.

Physical status modifiers include the following:

• P1 (Normal healthy patient): 0 units
• P2 (Patient with mild systemic disease): 0 units
• P3 (Patient with severe systemic disease): 1 unit
• P4 (Patient with severe systemic disease that is a constant threat to life): 2 units
• P5 (A moribund patient who is not expected to survive without the operation): 3 units
• P6 (A declared brain-dead patient whose organs are being removed for donor purposes): 0 units

Commercial payers will use these as pricing modifiers and will add additional base units for P3, P4, and P5. However, Medicare treats these as informational modifiers and does not reimburse for them.

According to Medicare Administrative Contractor (MAC) Noridian’s anesthesia modifier guidance, there are two types of anesthesia modifiers: pricing and informational.

Pricing modifiers include the following:

• AA (Anesthesia services performed personally by anesthesiologist)
• AD (Medical supervision by a physician: More than four concurrent anesthesia procedures)
• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)
• QX (Crna service: with medical direction by a physician)
• QY (Medical direction of one certified registered nurse anesthetist by an anesthesiologist)
• QZ (Certified registered nurse anesthetist service: Without medical direction by a physician)

Informational modifiers include the following:

• QS (Monitored anesthesia care service)
• G8 (Monitored anesthesia care (mac) for deep complex, complicated, or markedly invasive surgical procedure)
• G9 (Monitored anesthesia care for a patient who has a history of a severe cardiopulmonary condition)
• 23 (Unusual anesthesia): Used to report a procedure that usually requires either no anesthesia or local anesthesia but, because of unusual circumstances, must be performed under general anesthesia; coverage and payment are determined on a by-report basis

Stay Abreast of Current Payment Methodologies

The anesthesia fee schedule is a list of set prices that insurance companies, Medicare, or state programs will pay anesthesiologists or nurse anesthetists for specific anesthesia services.

Unlike regular medical procedures that have a set price, anesthesia is paid based on how long the service takes and how complex it is, using a formula described in the Medicare Claims Processing Manual and the U.S. Department of Labor Anesthesia Service and Reimbursement Policy:

(Base units + time units) x conversion factor

Base units are a set number of points assigned to an anesthesia code based on how complex, difficult, and risky the procedure is.

Time units are the total amount of time the anesthesia provider is directly monitoring and caring for the patient. Under the Medicare Claims Processing Manual, 1 time unit is equal to 15 minutes of anesthesia.

The conversion factor is a set dollar amount that Medicare determines each year or that is agreed upon with private insurance companies, and it may vary depending on location. Conversion factors are released annually by CMS. Both the base units and conversion factor are available via the CMS Anesthesiologists Information Center.

Ultimately, anesthesia services are an important part of many surgical and diagnostic procedures. Proper patient evaluation, anesthesia administration, monitoring, documentation, and postoperative care help ensure patient safety and quality care. Understanding anesthesia guidelines and coding requirements is also essential for accurate documentation and appropriate reimbursement.

Jen Methax, CPC, Consultant, Pinnacle Enterprise Risk Consulting Services