California Medical Bill Reviewer Certification

California Medical Bill Reviewer Certification

California Medical Bill Reviewer Certification Unit 2: Official Medical Fee Schedule Module 4: Anesthesia Overview Hi! In this module, you Lets start by will learn about Then, you will learn discussing general anesthesia services, how anesthesia how they are

anesthesia guidelines services are used for reimbursed, and the and how anesthesia pain management circumstances services arethat services. can affect reimbursed... reimbursement. Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Modifiers: Basic Modifiers Physical Status Modifiers

Qualifying Circumstances CA Regulations Training - Anesthesia What is Anesthesiology? Anesthesiology is the branch of medicine concerned with the control of acute or chronic pain. Anesthesia includes the use of: Sedative drugs Analgesic drugs Hypnotic drugs Anti-emetic drugs Respiratory drugs Cardiovascular drugs

CA Regulations Training - Anesthesia Anesthesia also involves: Preoperative assessment Intra-operative patient management Postoperative care Autonomic, neuromuscular, cardiac, and respiratory physiology Anesthesia Guidelines The anesthesia section in the OMFS ranges from 00100-01999.

Anesthesia codes do not correspond one-to-one with surgery codes because multiple surgery codes may crosswalk to the same anesthesia code. For example, CPT 01382 is used for anesthesia services for any arthroscopic procedure on the knee joint. CA Regulations Training - Anesthesia Therefore, 17 surgery codes correspond to this single anesthesia service. Single anesthesia codes correspond to multiple surgical codes because the

anesthesiologist performs the same tasks for any of the arthroscopic knee services and the only variation may be time. Anesthesia Services Anesthesiologists may bill for a variety of services and methods of anesthesia. Anesthesia Methods: General anesthesia Moderate sedation Regional anesthetic CA Regulations Training - Anesthesia

Anesthesia services include: Pre-operative visit with the patient. Ordering and giving medication. Monitoring the patients vital signs and level of sedation. Procedures not Separately Reimbursable Just like other procedures, some anesthesia procedures can be billed separately, while other procedures cannot be billed separately. Services not billed separately include: Pre and post-operative routine visits. Administration of fluids, including blood. Usual monitoring services such

as: EKG, temperature, blood pressure, oximetry, capnography, and mass spectrometry. Regulations Training - Anesthesia CA The system is automated to deny all non-invasive monitoring services billed with an anesthesia code. Separately Reimbursable Procedures In contrast, anesthesiologists can bill for invasive procedures. Some of these invasive

procedures include: CA Regulations Training - Anesthesia Insertion of a central venous catheter Esophageal catheter Swan-Ganz catheter Anesthesia Reimbursement Anesthesiologists are reimbursed per a base unit value assigned to each anesthesia code and by units of time. For up to 4 hours of service: 1 Time Unit = 15 minutes After 4 hours of service: 1 Time Unit = 10 minutes

Five minutes or more is considered significant enough for the final unit. CA Regulations Training - Anesthesia Calculations are automated but may be required in a manual pricing situation. Anesthesia Reimbursement CPT 00630: Anesthesia for lumbar spine surgery Duration: 5 hours, 35 minutes Base Units: 8 TIME UNITS: First 4 hours: What happens to 4 hours = 240 minutes the extra 5

minutes? 240 minutes/15 minutes per unit = 16 units TIME UNITS: Remaining 1 hr, 35 minutes: 335 240 = 95 minutes 95 minutes/10 minutes per unit = 9 units + 5 extra minutes Base Units + Time Units = Total Units 8 + 16 + ? = ? CA Regulations Training - Anesthesia Anesthesia Reimbursement Remember, 5 minutes or more is considered enough for a final unit. Therefore, we round the

remaining 5 minutes of time up to count as 1 whole unit! TIME UNITS: Remaining time: 335 240 = 95 minutes 95 minutes/10 minutes per unit = 10 9 +units 5 extra minutes Base Units + Time Units = Total Units 8 + 16 + 10 = 34 CA Regulations Training - Anesthesia Anesthesia Reimbursement CPT 01202: Anesthesia for hip arthroscopy Duration: 1 hours, 3 minutes Base Units: 4 Where did the last 3 minutes go? Remember, only 5 minutes or more can be reimbursed as a 1 hour, 3 minutes = 63 final unit.

minutes 60 minutes/15 minutes per unit So, in this case, we round down = 4 units to 60 minutes, or 4 units! TIME UNITS: 1 hour, 3 minutes: Base Units + Time Units = Total Units 4+4=8 CA Regulations Training - Anesthesia Modifiers Now that you are familiar with the We will begin by basics of anesthesia, lets discuss discussing a fewhow

basic modifiers and extreme anesthesia modifiers... circumstances can alter reimbursement. Part I: Anesthesia Anesthesia Guidelines Reimbursement of Anesthesia Services Modifiers: Basic Modifiers Physical Status Modifiers Qualifying Circumstances CA Regulations Training - Anesthesia Modifiers As you know, each section of the OMFS has a list of modifiers that pertain to those services. We will discuss the

following modifiers: Recall that modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. CA Regulations Training - Anesthesia Modifier 36 Modifier 47 Modifier 48 See the OMFS for a complete list of modifiers! Modifier 36

In some instances, special circumstances warrant an increase in the basic value of specific procedures. Procedures with a basic value of three or less base units which: Require endotracheal intubation for prone or other difficult positions Require surgical field avoidance Are performed for medical necessity ...may warrant an additional charge. CA Regulations Training - Anesthesia 36 Anesthesia Procedures: This modifier increases the basic value for these procedures to four base units. Other applicable modifiers also apply.

Modifier 47 In some instances, anesthesia is provided by a surgeon, rather than an anesthesiologist. 47 Anesthesia by Surgeon: regional anesthesia provided by a surgeon. No time units are applied. It is important to realize that Modifier 47 should only be billed with surgical codes, not anesthesia codes. CA Regulations Training - Anesthesia Certified Registered Nurse Anesthetists Certified Registered Nurse Anesthetists (CRNA) also administer anesthesia, although they must be under the supervision of an anesthesiologist.

Both the anesthesiologist and the CRNA are reimbursed. The anesthesiologist is paid for the base units and a reduced number of time units. The CRNA is paid the remainder of the total reimbursement of an anesthesiologist performing the service. CA Regulations Training - Anesthesia To be eligible for reimbursement, the anesthesiologist must be within hearing and visual range, and cannot

supervise more than 2 rooms, or administer anesthesia himself. Lastly, the anesthesiologist must be involved in the medical direction of the patient, including pre and postoperative care. Modifier 48 Modifier 48 indicates that a CRNA performed anesthesia services. 48 Reduced Anesthesia Value for Supervising Anesthesiologist: Reimbursement for the supervising physician shall be for the basic value of the procedure plus one unit per hour or fraction thereof for the duration of the anesthesia. Total reimbursement to the CRNA and supervising anesthesiologist shall not exceed the listed value of the service if performed by an anesthesiologist.

CA Regulations Training - Anesthesia Certified Registered Nurse Anesthetists Suppose Dr. Jones supervises two operating rooms with CRNAs giving anesthesia in each. He does not administer the anesthesia himself. Operating Room 1 CA Regulations Training - Anesthesia Dr. Jones Operating Room 2 Certified Registered Nurse Anesthetists Operating Room 1 Duration:

1 hour, 15 minutes Base Value = 4 CA Regulations Training - Anesthesia Operating Room 2 Dr. Jones Duration: 45 minutes Base Value = 6 Certified Registered Nurse Anesthetists Operating Room 1 15 minutes Duration: 1 hour, Base Value = 4 75 minutes = 5 units Total Units = 9 Anesthesiologist: 1 unit/hour (or fraction thereof) = 2 time unitsTotal = 2 + 4 Anesthesiologist

CRNA: 9 = 66 = 3 Units CA Regulations Training - Anesthesia Operating Room 2 Duration: 45 minutes Base Value = 6 45 minutes = 3 units Now you try... Total Units =9 How many units can unit be Anesthesiologist: 1 time reimbursed to the anesthesiologist and=the Anesthesiologist Total 1 +CRNA? 6=7 CRNA: 9 7 = 2 Units

Physical Status Modifiers In addition to standard modifiers, there are other modifiers, known as physical status modifiers, which can affect the reimbursement of anesthesia services. CA Regulations Training - Anesthesia Physical Status Modifiers Anesthesia complicated by the patients condition may be additionally reimbursed if documentation supports the presence of significant disease. These significant complications are indicated by physical status modifiers.

While hypertension and diabetes are not considered significant enough to warrant use of the higher level physical status modifiers, conditions such as: Congestive heart failure Emphysema Uncontrolled epilepsy ...are reimbursable. CA Regulations Training - Anesthesia Physical Status Modifiers The physical status modifiers and their values are: Modifie r Description

Uni t P1 normal, healthy patient 0 P2 patient with mild systemic disease 0 P3 patient with severe systemic disease 1 P4 patient with severe systemic disease that is a constant

threat to life 2 P5 moribund patient not expected to live without the surgery 3 P6 brain dead patient for harvesting 0 CA Regulations Training - Anesthesia Anesthesia Reimbursement CPT 01402: Anesthesia for total knee replacement Duration: 3 hours, 25 minutes Complication: Patient has congestive heart failure (P3: 1 unit) Base Units: 7 TIME UNITS:

3 hours, 25 minutes: Remember, 195 minutes/15 min. per unit = 13 That leaves 10 minutes remaining. 3 hours, 25 minutes = 205 minutes So, we round up to account for 1 205 minutes/15 minutes per extra unit, for a total of 14 time unit units! = 13 units + 10 extra minutes Base Units + Time Units + P3 Modifier Units= Total Units 7 + 14 + 1 = 22 CA Regulations Training - Anesthesia Physical Status Modifiers Some providers will attach a physical status modifier to all anesthesia services, while others will only

attach those with unit values greater than zero. Either method is acceptable and the system is automated to pay the modifier. It is the processors responsibility to verify that documentation justifies the addition of the payable modifiers. CA Regulations Training - Anesthesia Qualifying Circumstances As you know, physical status modifiers indicate significant complications. Similarly, there are special codes that indicate other extreme

circumstances that can affect the reimbursement of anesthesia services. CA Regulations Training - Anesthesia Qualifying Circumstances You have probably realized that there are certain circumstances which make giving anesthesia much more difficult. If the patient is extremely old Certain surgical procedures, or extremely young, the such as cardiovascular or intracranial surgery, require reaction to the anesthetic lowering the blood pressure or medications may be very body temperature significantly different and must be to reduce bleeding. monitored more closely.

These circumstances are known as qualifying circumstances, and are billed in addition to anesthesia services. CA Regulations Training - Anesthesia Qualifying Circumstances Qualifying circumstances are indicated by special codes, not modifiers. Qualifying Circumstance codes include: 99100 Anesthesia for patient of

extreme age, under one year or over seventy. 99116 Anesthesia complicated by utilization of total body hypothermia. 99135 Anesthesia complicated by utilization of controlled hypotension. 99140 Anesthesia complicated by emergency conditions (specify). CA Regulations Training - Anesthesia Qualifying Circumstances It is critical that documentation support the addition of qualifying circumstances. The age of a patient is easily verified to confirm an instance of extreme age. CA Regulations Training - Anesthesia

In contrast, hypothermia can only be justified if, in the report, there is documentation stating that a hypothermia pad or blanket was placed under the patient and used to drop the body temperature. Qualifying Circumstances You probably realize that like other providers, anesthesiologists can incorrectly bill for certain codes. Qualifying circumstance code 99135 is often incorrectly billed by anesthesiologists who simply keep a patients hypertension under control or lower the

blood pressure slightly to minimize bleeding. CA Regulations Training - Anesthesia 99135 should only be reimbursed if documentation shows a significant reduction in the blood pressure at least 20 points for delicate surgery such as intracranial operations. Pain Management Now that you are familiar with how anesthesia is generally used, lets discuss how it can be used for pain management.

Part II: Pain Management Services Post-operative Pain Control Chronic Pain Control CA Regulations Training - Anesthesia Pain Management Services Pain management occurs in two distinct circumstances: Post-operative Pain Control CA Regulations Training - Anesthesia Chronic Pain Control Pain Management Services If a spinal, epidural, or regional anesthetic is used for anesthesia during a surgery instead of general anesthesia, the anesthesiologist should still bill with the correct anesthesia code associated with the procedure.

This is because the service includes the anesthetic and all monitoring necessary to bring the patient safely through the surgery, regardless of the type of anesthetic. CA Regulations Training - Anesthesia Post-operative Pain Control Post-operative Pain Control CA Regulations Training - Anesthesia However, if a general anesthetic is given, making the patient unconscious, and the anesthesiologist gives an epidural or regional block for postoperative pain control

in addition to the anesthesia given for the surgery, it can be billed separately. Post-operative Pain Control Example 1 Example 2 Bob Smith is having a meniscectomy performed in his right knee. Bob Smith is having a meniscectomy performed in his right knee. He and the anesthesiologist discuss the anesthetic options and decide he will be happiest with an epidural anesthetic, making him numb from the waist down, and some mild IV sedation for anxiety control. He and the anesthesiologist discuss the anesthetic options and decide he

will be happiest with a general anesthetic because his anxiety level is so high. In addition, the anesthesiologist will insert an epidural catheter for pain control in the 24 hours following surgery. The anesthesiologist will code her services with 01382 for basic value and time but will not bill separately for the epidural insertion. CA Regulations Training - Anesthesia The catheter insertion is separately reimbursed because it is not part of the anesthetic for the surgery. The anesthesiologist may not bill 01996 for pain control management on the day of surgery. Post-operative Pain Control Just like other procedures, the

surgeon cannot bill separately for pain control services, such as inserting a pain pump catheter, if it is performed as part of the surgery. CA Regulations Training - Anesthesia In this case, it is part of the global surgery package. Chronic Pain Control In chronic pain management, anesthesiologists that specialize in pain control may see the patient for a single or a series of injections, either into a joint or body area, or into the epidural space.

They may also employ noninjection methods of pain control such as biofeedback, physical therapy, and counseling. However, the most common treatment is injection. CA Regulations Training - Anesthesia Chronic Pain Control Chronic Pain Control In California, like any other specialty who performs these services, these injections are billed and reimbursed as Type of Service (TOS) 2, which is surgery. If these services are billed as TOS 7, which is anesthesia, the processor must change the TOS to reflect that this is a surgical service.

CA Regulations Training - Anesthesia Chronic Pain Control Anesthesiologists often used the American Society of Anesthesiologists (ASA) Relative Value Guide to bill for particular services. This reference guide lists the recommended base values for each procedure. Often, anesthesiologists will mistakenly indicate the anesthesia base value in the units field on the bill. CA Regulations Training - Anesthesia Remember, the bill review system already calculates the base value associated with a procedure. Chronic Pain Control

As you can see, when reviewing bills, it is important to determine the type of units and verify that they coincide with the service provided. If multiple units are billed, the processor must determine if the provider has: performed multiple injections billed for time units indicated the anesthesia base value of the service in the unit field Unfortunately, all the above scenarios are viable possibilities. CA Regulations Training - Anesthesia Chronic Pain Control

Example Suppose a provider bills CPT 20610: large joint injection, for 3 units. As a processor, you should ask, Is he billing for 3 injections or 3 time units? Or, is this the base value?" Only documentation can verify if this represents injections of both hips and one knee, for a total of 3 injections... ...or a single injection took the anesthesiologist 45 minutes, for a total of 3 time units. CA Regulations Training - Anesthesia Chronic Pain Control 3 Joint Injections: left hip, right hip, & right knee 3 Injections The lines are separated, and

the procedures are reimbursed at multiple procedure cascade. Left hip: 20610 x 100% of FS value Right hip: 20610 x 50% of FS value CA Regulations Training - Anesthesia Right knee: 20610 x 25% of FS value Chronic Pain Control Single large joint injection representing time units or ASA base value 3 Time Units The processor will need to change the unit field to 1 and the TOS to 2 to represent the actual service performed.

1 injection Billed: 20610, TOS 7, Units: 3 Paid: 20610 x 100% of FS value TOS 2, Units: 1 CA Regulations Training - Anesthesia Chronic Pain Control If multiple types of injections are performed, they are reimbursed at multiple procedure cascade. Example: 62278 lumbar epidural: 100% FS 64440 injection paravertebral nerve: 50% FS 20550 trigger point injection: 25% FS CA Regulations Training - Anesthesia

If the provider appeals the recommendation, he is educated on multiple cascade logic, which avoids duplicating reimbursement for overhead, pre-operative, and postoperative care. Pain Management Services A common error in pain management occurs when providers bill for an E & M service each time the patient comes in for an injection. If a pattern, such as weekly visits is obvious, it is unlikely each visit was a significant, separately identifiable service and not just routine questioning about pain level. CA Regulations Training - Anesthesia Unless the provider is

assessing the patients progress in detail, treating an additional condition, or teaching or counseling the patient extensively, the E/M service is included in the injection procedure payment. Summary Anesthesia: Services and Procedures Modifiers: How basic and physical status modifiers affect reimbursement. What constitutes qualifying circumstances. CA Regulations Training - Anesthesia

How to calculate anesthesia reimbursements. How postoperative pain control services are reimbursed. How chronic pain control services are reimbursed. Module Quiz Its time to check your knowledge of the concepts presented in this module. This quiz is scored. You must achieve a score of 80% to pass. You may attempt this quiz as many times as needed to achieve a passing score.

When finished, you may move on to the next module. CA Regulations Training - Anesthesia CA MBR Unit 2 Module 4 Quiz PROPERTIES On passing, 'Finish' button: On failing, 'Finish' button: Allow user to leave quiz: User may view slides after quiz: User may attempt quiz: CA Regulations Training - Anesthesia Goes to Next Slide Goes to Next Slide After user has completed quiz At any time Unlimited times

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