Notification

Reporting and Documentation Requirements for Anesthesia Services


Notification Issue Date: 10/01/2018

As of 01/01/2019, revised policy number 00.01.14q is being issued to make a change to reimbursement methodology for anesthesia services. Reimbursement for the physical status modifiers (P1-P6) will be discontinued. Going forward, these modifiers are to be reported for informational purposes only.



Claim Payment Policy


Title:Reporting and Documentation Requirements for Anesthesia Services

Policy #:00.01.14q

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Anesthesia services performed by a professional provider in an anesthesia specialty (i.e., anesthesiologist, certified registered nurse anesthetist [CRNA]), in conjunction with a medically necessary procedure or service, are covered and eligible for reimbursement consideration by the Company when the services are reported in accordance with this policy and the appropriate documentation is included in the claim and in the individual's medical record.
  • For a list of the American Society of Anesthesiologists (ASA) anesthesia procedure codes, refer to Attachment A in this policy.
  • For a list of modifiers and other anesthesia related codes, refer to the Coding Table in this policy.

When anesthesia and emergency intubation are performed on the same date of service and performed by the same professional provider or provider group (i.e., anesthesiologists, CRNAs), both services are eligible for separate reimbursement consideration.

Anesthesia administered for procedures for which the corresponding procedure code, by definition, includes moderate sedation is covered and eligible for reimbursement consideration. However, both of the following must be met:
  • The individual's condition at the time of the procedure must necessitate the administration of anesthesia and must be documented in the medical record.
  • All other coverage, reporting, documentation, and eligibility requirements must be met.

The Company applies the following standard anesthesia calculation formula to determine reimbursement for eligible anesthesia services reported in minutes:
  • Reported anesthesia minutes divided by 15. (Round to one decimal place to calculate the time unit.)
  • Calculated time unit + base unit x conversion factor
    • The Company calculates reimbursement using the Centers for Medicare & Medicaid Services (CMS) anesthesia base units. Base units must not be reported with an anesthesia procedure code.
  • Modifier AD, QK, QX, or QY must be reported when a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed qualified nonphysician anesthetist. The payment amount for the service of each is 50 percent of the calculated allowance.
  • Modifier AA must be reported when it is medically necessary for the anesthesiologist to be completely and fully involved during a procedure. The payment amount for the service of each is 100 percent of the calculated allowance.
  • Modifier QZ must be reported when it is medically necessary for the medically directed qualified nonphysician anesthetist or CRNA to be completely and fully involved during a procedure without medical direction by a anesthesiologist. The payment amount for the service of each is 100 percent of the calculated allowance.
  • Physical status modifiers (P1 through P6) are informational only and not eligible for additional reimbursement when reported.

MEDICAL DIRECTION

The medical direction by an anesthesiologist or a CRNA is covered and eligible for reimbursement consideration when all of the following requirements are met:
  • The appropriate medical direction modifier is reported in conjunction with the appropriate anesthesia procedure code.
  • The anesthesiologist is not medically directing more than four anesthesia procedures concurrently.
  • The anesthesiologist is physically present or immediately available in the operating suite.

ANESTHESIA SERVICES PERFORMED BY QUALIFIED SPECIALISTS IN OBSTETRICS (OB), OBSTETRICS/GYNECOLOGY (OB/GYN), AND ORAL SURGERY

Epidural anesthesia performed for maternal labor pain analgesia is covered and eligible for reimbursement consideration when performed by a qualified specialist in OB or OB/GYN.

Anesthesia and sedation (i.e. moderate sedation and deep sedation) services performed for covered dental or oral surgery procedures are covered and eligible for reimbursement consideration when performed by an eligible professional provider who specializes in oral surgery and who has met all the licensing and certification requirements for the performance of anesthesia services in the state where the services are performed. Refer to the Coding Table in this policy for a list of eligible dental and oral surgery sedation and anesthesia codes.

Anesthesia performed for non-covered dental or oral surgery procedures may be covered and eligible for reimbursement consideration in accordance with applicable Company policies and federal and/or state mandates.

ANESTHESIA FOR MULTIPLE PROCEDURES

Anesthesia administered for multiple covered procedures performed during the same operative session is covered and eligible for reimbursement consideration. In such cases, the anesthesia code for the most complex procedure (i.e., the highest base unit value) is reported with the combined time of the anesthesia procedures that are eligible to be reported for time. However, do not report time for anesthesia codes that are identified in this policy as not eligible to be reported in minutes.

ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS

Refer to the Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Pain Management policy regarding the coverage position of procedure codes 01991 and 01992.

MONITORED ANESTHESIA CARE (MAC)

MAC is covered and eligible for reimbursement consideration on the same basis as other covered anesthesia services performed by a professional provider in an anesthesia specialty. However, the medical record must substantiate the necessity for MAC and must be available to the Company upon request. The provision of MAC requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic.

When MAC is performed, the reported anesthesia procedure code must be appended with the appropriate MAC modifier.

ANESTHESIA SERVICES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Services that are integral to the basic anesthesia service are not eligible for separate reimbursement consideration. These services include, but are not limited to, the following:
  • The final preanesthetic evaluation of the individual, which is routinely performed immediately prior to anesthesia administration and surgery
    • Refer to the policy addressing preoperative consultations performed by providers in anesthesia specialties.
  • Preparation for and the administration of anesthesia medications
  • Administration of fluids and/or blood
  • Routine monitoring (e.g., temperature, oximetry, electrocardiogram [ECG/EKG], blood pressure, capnography, mass spectrometry)
  • Postoperative evaluation and management related to the surgery
    • Management of epidural or subarachnoid drug administration (procedure code 01996) is eligible for separate reimbursement consideration on dates of service subsequent to the surgery, not on the date of surgery.
    • Management of epidural or subarachnoid drug administration (procedure code 01996) should be billed once per day as a single unit for each day that the individual receives anesthesia.
  • Sedation administered prior to or to facilitate induction or as part of covered MAC services.
  • Qualifying circumstances procedure codes 99100, 99116, 99135, and 99140
    • These are always bundled procedure codes.
    • Refer to the Always Bundled Procedure Codes policy.

Reimbursement for local anesthesia and all other sedation services are integral to the reimbursement for the corresponding procedure and is not eligible for separate reimbursement unless otherwise stated in this policy.

NON-COVERED ANESTHESIA SERVICES

Anesthesia services performed in conjunction with non-covered services are not covered and, therefore, not eligible for reimbursement, with the exception of those anesthesia services mandated by federal and/or state law.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. Additionally, the medical record must clearly document who administered the anesthesia, the time minutes (including any interruptions to the administration of the anesthesia), and any other documentation requirements listed in this policy.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Anesthesia services reported in minutes.

Unless otherwise noted, time is reported for anesthesia services in minutes. If the provider's anesthesia service is interrupted for a short duration, the total number of minutes should be reported, less the number of minutes representing the interruption.

Anesthesia services not reported in minutes.

FLAT RATE
  • The following anesthesia codes are not based on time and, when eligible, are reimbursed at a flat rate: 01960, 01967, 01996.

DENTAL ANESTHESIA CODES
  • The following dental anesthesia codes, when eligible, are reimbursed in units: HCPCS codes D9222, D9223, D9239, D9243.

BURN DEBRIDEMENT

The burn debridement anesthesia add-on code (procedure code 01953) is eligible for separate reimbursement consideration when it is reported with the corresponding primary anesthesia procedure code (procedure code 01952). However, the combined total (in minutes) of the anesthesia time associated with both the primary and add-on anesthesia procedures is submitted with the primary anesthesia code, not the add-on code.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

The postoperative period and global surgery rules do not apply to the procedure codes representing the administration of anesthesia.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, anesthesia services performed by professional providers in anesthesia specialties or qualified specialists in obstetrics (OB), Obstetrics/Gynecology (OB/GYN), and oral surgery are covered under the medical benefits of the Company’s Medicare Advantage products.

BILLING GUIDELINES

The administration of epidural anesthesia for non-obstetrical diagnoses should be reported using the appropriate surgical procedure code.

Professional providers should report procedure code 01996 on a CMS 1500 form or the electronic equivalent 837p, with each date of service reported separately. Date spans should not be reported.

Description

Anesthesia is the partial or complete depression of sensation (analgesia) with or without loss of consciousness as a result of the administration of an anesthetic agent. There are three major categories of anesthesia:
  • General anesthesia may be administered via inhalation of a vapor or gas and/or via injection of a liquid to attain insensitivity to pain, amnesia, and unconsciousness, characterized by a partial or complete loss of protective reflexes, the inability to independently maintain an airway, and the inability to respond purposefully to commands.
  • Regional anesthesia, which is divided into spinal, saddle, epidural, caudal, and nerve blocks, uses a local anesthetic injected into a specific body region to attain insensitivity and limited or total immobility, while maintaining the individual's consciousness.
  • Local (or topical) anesthesia uses an anesthetic agent to interrupt the initiation and transmission of nerve impulses, thereby resulting in numbness or loss of sensation in an area.

Medical direction is the supervision of anesthesia as direction, management, or instruction by an anesthesiologist who is physically present or immediately available in the operating suite, or a certified registered nurse anesthetist (i.e., CRNA). An anesthesiologist who provides medical direction does not actually administer anesthesia but must be available to provide anesthesia or perioperative intervention if required.

Monitored anesthesia care (MAC) is the intraoperative monitoring by a provider in an anesthesia specialty (i.e., anesthesiologist, CRNA) of an individual’s vital physiological signs in anticipation of either the need for general anesthesia and/or the development of an adverse physiological reaction to the surgical procedure (e.g., hypotension). This monitoring includes the following: an evaluation of the patient's oxygenation, ventilation, circulation, and temperature; a preanesthetic examination and evaluation; prescription of the anesthesia care required; administration of any necessary oral or parenteral medications (e.g., sedation and analgesia medications); and the provision of postoperative anesthesia care.

Sedation involves the use of central nervous system (CNS)--depressing medications to obtain a calmed and medically controlled mental state. The level of CNS suppression varies with the type and dose of medication administered.
  • Moderate sedation, also referred to as conscious sedation, is the administration of moderate sedation/analgesia to achieve a medically controlled state of depressed consciousness while minimizing the individual's discomfort through the use of pain relievers and sedatives. The individual's airway, protective reflexes, and ability to respond to stimulation or verbal commands are maintained.
  • Deep sedation is a drug induced depression of consciousness during which individuals cannot be easily aroused but may respond following repeated or painful stimulation. Individuals may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Generally, most anesthesia administration services are reported using the American Society of Anesthesiologists (ASA) procedure codes. However, there are other procedure codes available to represent dental anesthesia, infusions, injections for pain, local/topical analgesia, and sedation services that are outside of the ASA procedure code range.

Anesthesia time is used as part of the formula for determining the reimbursement for most anesthesia services. Anesthesia time is a continuous time period, in minutes, from the time the anesthesia provider initiates preparation of the patient for anesthesia care in the operating room or equivalent area, until the time when the anesthesia provider is no longer in personal attendance (i.e. when the patient may be placed safely under postoperative supervision). One time unit is applied to each 15 minute increment.

Anesthesia base units are the value assigned to most anesthesia services. This value is based on the comparative difficulty of the anesthesia administered, including the usual preoperative and postoperative care and evaluation, and is part of the formula used to determine reimbursement for anesthesia services. The Company applies the Centers for Medicare & Medicaid Services (CMS) anesthesia base units to anesthesia services with an assigned value.

Anesthesia qualifying circumstances codes reflect the variable circumstances or conditions (e.g., complications due to an emergency condition, a patient's advanced age) that require additional skill and/or intervention by the anesthesia provider that is beyond those usually required.

Anesthesia modifiers are two digit alphanumeric codes that are used to indicate additional information about anesthesia procedures and services for the processing of anesthesia claims. For example, an anesthesia modifier may indicate who performed the anesthesia service or the physical status of the individual (P1-P6). The physical status modifiers identify levels of complexity of the anesthesia services and are reported in conjunction with anesthesia procedure codes when appropriate.

The conversion factor is the dollar value multiplied by the total units (time unit + base unit) to equal the reimbursement for most anesthesia services.
References


Centers for Medicare & Medicaid Services (CMS). Anesthesiologists Center. Anesthesia Base Units by CPT Code [CMS Web site]. Available at:http://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html. Accessed May 17, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician practitioners. 50 - Payment for anesthesiology services. [CMS Web site]. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 17, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants.[CMS Web site]. Available at:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/APNPA.html. Accessed May 17, 2018.

Optum360. Understanding Modifiers 2018. West Salt Lake City, UT: Optum360; 2017.

State of New Jersey (NJ). Rules and regulations of the Division of Consumer Affairs Title 13, Chapter 35, Subchapter 4A: Surgery, special procedures, and anesthesia services performed in an office setting. [NJ Department of Law & Public Safety Web site]. Available at: http://www.njconsumeraffairs.gov/regulations/Chapter-35-Board-of-Medical-Examiners.pdf#search=%20Title%2013%2C%20Chapter%2035%2C%20Subchapter%204A. Accessed May 17, 2018.

State of Pennsylvania. The Pennsylvania Code. Health and Safety. Chapter 123: Anesthesia and respiratory services. A: Anesthesia services. Title 28, 123.14: Written policies. [PA Code Web site]. Available at: http://www.pacode.com/secure/data/028/chapter123/chap123toc.html. Accessed May 17, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

FOR A LIST OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS' (ASA) ANESTHESIA PROCEDURE CODES (00100-01999), REFER TO ATTACHMENT A.

QUALIFYING CIRCUMSTANCES CODES

99100, 99116, 99135, 99140


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



DENTAL/ORAL SURGERY SEDATION AND ANESTHESIA CODES

REPORT THE FOLLOWING CODES IN UNITS:

D9222 deep sedation/general anesthesia – first 15 minutes

D9223 deep sedation/general anesthesia - each subsequent 15 minute increment

D9239 intravenous moderate (conscious) sedation/analgesia- first 15 minutes

D9243 intravenous moderate (conscious) sedation/analgesia – each 15 minute increment


Revenue Code Number(s)

N/A


Misc Code

MODIFIERS:

A MODIFIER FROM THE FOLLOWING LIST IS REQUIRED TO BE REPORTED WHEN REPORTING ANY ANESTHESIA PROCEDURE CODE LISTED IN ATTACHMENT A:

    PERFORMANCE VERIFICATION MODIFIERS:

    AA: Anesthesia services performed personally by anesthesiologist

    AD: Medical supervision by a physician; more than 4 concurrent procedures

    QK: Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals

    QX: CRNA service with medical direction by a physician

    QY: Medical direction of 1 CRNA by an anesthesiologist

    QZ: CRNA service without medical direction by a physician

    MONITORED ANESTHESIA CARE (MAC) MODIFIERS:

    QS: Monitored anesthesia care service

    G8: Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure

    G9: Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition


    PHYSICAL STATUS MODIFIERS:

    P1: A normal healthy patient

    P2: A patient with mild systemic disease

    P3: A patient with severe systemic disease

    P4: A patient with severe systemic disease that is a constant threat to life
    P5: A moribund patient who is not expected to survive without the operation

    P6: A declared brain-dead patient whose organs are being removed for donor purposes


Coding and Billing Requirements


Cross References

Attachment A: Reporting and Documentation Requirements for Anesthesia Services
Description: AMA Anesthesia Procedure Codes



Policy History

REVISIONS FROM 00.01.14q:
01/01/2019As of 01/01/2019, revised policy number 01.01.14q is being issued to make a change to reimbursement methodology for anesthesia services. Reimbursement for the physical status modifiers (P1-P6) will be discontinued. Going forward, these modifiers are to be reported for informational purposes only.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2019
Version Issued Date: 12/31/2018
Version Reissued Date: N/A

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