Wiki Obstetrical Anesthesia reimbursement 01967

[jmad456]

Should obstetrical anesthesia (basically the epidural under code 01967) be reimbursed in the same way as anesthesia for a surgery based on the minutes calculated with a conversion factor? We have a anesthesia group who bills the minutes from the start to end even though they are not present the entire time. They are than reimbursed for hours and hours of anesthesia time which results in huge payments, sometimes beyond what the hospital charges for the entire maternity stay.

I Found this link which suggests that code 01967 is for 4 hours or less and if more to add modifier 23. http://www.anesthesiabilling.org/2016/06/anesthesia-during-delivery-cpt-codes.html
This makes me think that these should be reimbursed with a flat rate rather than based on minutes like typical anesthesia.
Scenarios:

• For labor less than 4 hours ending in vaginal delivery : CPT code 01967

• For labor less than 4 hours ending in a cesarean delivery: CPT code 01967 and 01968

• For labor ending in an urgent or emergency cesarean delivery, CPT code 99140 may be billed with CPT code 01967 and 01968

• For labor 4 hours or more ending in a vaginal delivery: CPT code 01967 with modifier 23

• For labor 4 hours or more ending in a cesarean delivery : CPT code 01967 with modifier 23 and add on CPT code 01968

• For labor ending in an urgent or emergency cesarean delivery: CPT code 01967 with add-on code 01968 and 99140

 

[thomas7331]

Most payers I've worked with do reimburse these at flat rates, or apply caps to the amount of time they will pay for anesthesia during labor, rather than paying on a fee schedule or based on total time. But this would be governed by payer policy and provider contracts - it can vary considerably from one payer and one provider to another.

 

[pscanlan]

Should obstetrical anesthesia (basically the epidural under code 01967) be reimbursed in the same way as anesthesia for a surgery based on the minutes calculated with a conversion factor? We have a anesthesia group who bills the minutes from the start to end even though they are not present the entire time. They are than reimbursed for hours and hours of anesthesia time which results in huge payments, sometimes beyond what the hospital charges for the entire maternity stay.

The situation you are describing is commonplace. They can get away with billing for time that they're "not there" because they're technically on call for the duration of the procedure. Welcome to the world of physician income, where the amounts are staggering and make you feel bad about your own bank balance

But seriously, I've seen anesthesia docs make twice what the surgeon made on a given procedure, sometimes triple or quadruple, depending on the procedure. It's obscene, but not out of the norm. Check out colonoscopy reimbursement rates for another example of this.

Most payers I've worked with do reimburse these at flat rates, or apply caps to the amount of time they will pay for anesthesia during labor, rather than paying on a fee schedule or based on total time. But this would be governed by payer policy and provider contracts - it can vary considerably from one payer and one provider to another.

This. Much of the payment for anesthesia will depend on the contracted rates. Some payers will pay per unit or per minute, but most (including many state Medicaid carriers) will either cap the minutes at some arbitrary level, or pay a flat rate.

I'd suggest getting with your credentialing/enrollment/provider services department and going over the contracted rates with them to make sure you're receiving what you should be.

 

[jmad456]

The situation you are describing is commonplace. They can get away with billing for time that they're "not there" because they're technically on call for the duration of the procedure. Welcome to the world of physician income, where the amounts are staggering and make you feel bad about your own bank balance

But seriously, I've seen anesthesia docs make twice what the surgeon made on a given procedure, sometimes triple or quadruple, depending on the procedure. It's obscene, but not out of the norm. Check out colonoscopy reimbursement rates for another example of this.


This. Much of the payment for anesthesia will depend on the contracted rates. Some payers will pay per unit or per minute, but most (including many state Medicaid carriers) will either cap the minutes at some arbitrary level, or pay a flat rate.

I'd suggest getting with your credentialing/enrollment/provider services department and going over the contracted rates with them to make sure you're receiving what you should be.

Thank you for your quick replies. I actually work for a payer that routinely pays $5000 plus for epidurals because for whatever reason their contract doesn't cap their payment at what they bill- which happens to be a flat rate regardless of the minutes. I was hoping there might be some teeth in the time reporting guideline of ending "when no longer in personal attendance" as that seems different than being on call.