Current through Register Vol. 50, No. 9, September 20, 2024
A. General. The
total anesthesia allowance is calculated by adding the basic value units, time
value units, plus any applicable modifier unit values and/or unusual qualifying
circumstances units and multiplying the sum by a dollar amount allowed per
unit.
1. Basic Units. A basic unit is listed
for most procedures. The allowable basic units are shown in the following
schedule. When multiple surgical procedures are performed during the same
period of anesthesia, only the greater basic unit allowance of the various
surgical procedures will be used as the base. The basic value for each
procedure includes pre- and post-operative visits, administration of fluids
and/or blood incident to the anesthesia care and interpretation of noninvasive
monitoring (EKG, temperature, blood pressure, oximetry capnography and mass
spectrometry). When multiple surgical procedures are performed during the same
period of anesthesia, only the highest base unit allowance of the various
surgical procedures will be used.
2. Time Units. Time begins when the
anesthesiologist begins to prepare the patient anesthesia care in the operating
room or in a equivalent area. Time ends when anesthesiologist is no longer in
personal attendance, that is, when the patient may be safely placed under
postoperative supervision. The anesthesia time units will be calculated in
15-minute intervals, or portions thereof, equaling one time unit. In each
instance, five minutes or greater is considered a significant portion of a time
unit. No additional time units are allowed for recovery room time and
monitoring.
3.
a. Modifier Units. Physical status modifiers
are represented by the letter "P" followed by a single digit defined below.
|
i.
|
Healthy Patient
|
0
|
|
ii.
|
Patient with mild systemic disease
|
0
|
|
iii.
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Patient with severe systemic disease
|
1
|
|
iv.
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Patient with severe systemic disease threat to
life
|
2
|
|
v.
|
A moribund patient who is not expected to survive
without the operation
|
3
|
|
vi.
|
A declared brain-dead patient whose organs are
being removed for donor purposes
|
0
|
|
The above six levels are consistent with the
American Society of Anesthesiologist (ASA) ranking of patient physical status.
|
|
Example: 00100-P1
|
4. Qualifying circumstances warrant
additional value due to unusual events. The following list of CPT-4 codes and
the corresponding anesthesia unit values may be listed if appropriate. More
than one code may be necessary. The unit value listed is added to the existing
anesthesia base units.
|
CPT-4
|
Units
|
|
99100
|
Anesthesia for patient of extreme age, under one
year and over 70
|
1
|
|
99116
|
Anesthesia complicated by utilization of total
body hypothermia
|
5
|
|
99135
|
Anesthesia complicated by utilization of
controlled hypotension
|
5
|
|
99140
|
Anesthesia complicated by emergency conditions
(specify)
|
2
|
|
(An emergency is defined as existing when delay in
treatment of a patient would lead to a significant increase in the threat to
life or body part.)
|
5.
Any procedure around the head, neck or shoulder girdle requiring field
avoidance or any other procedure requiring a position other than supine or
lithotomy, has a basic value of 5.0 units regardless of any lesser value
assigned to such procedure. A medical report must be attached to document the
special unit.
6. Unlisted Service
or Procedure. When an unlisted service or procedure is provided, the value
should be substantiated "by report." These services are shown in this schedule
as "BR."
7. Procedures Listed
without Specified Unit Values. "BR" in the value column indicates that the
value of this service is to be determined "by report" because the service is
too unusual or variable to be assigned a unit value.
8. Monitored Anesthesia Care. Monitored
anesthesia care occurs when the attending physician requests that an
anesthesiologist be present during a procedure. This may be to insure
compliance with accepted procedures of the facility. Monitored Anesthesia Care
includes pre-anesthesia exam and evaluation of the patient. The
anesthesiologist must participate or provide medical direction for the plan of
care. The anesthesiologist, resident, or nurse anesthetist must be in
continuous physical presence and provide diagnosis and treatment of
emergencies. This will also include noninvasive monitoring of cardiocirculatory
and respiratory systems with administration of oxygen and/or intravenous
administration of medications. Reimbursement will be the same as if general
anesthesia had been administered (time units + base units).
9. More Than One Anesthesiologist. When it is
necessary to have a second anesthesiologist, the necessity should be
substantiated by report "BR." It is recommended that the second
anesthesiologist receive 5 base units + time units (calculation of total
anesthesia value).
10. Amount
Payable
a. The amount payable for anesthesia
services will be the lesser of the actual charge or $50 times the total allowed
units as determined by this schedule and the above guidance.
b. The total anesthesia allowance is
calculated by adding the basic unit value, the number of time units, plus any
applicable modifier and/or unusual circumstance units and multiplying the sum
by the $50 allowed per unit.
c.
When non-anesthetic procedures are performed by anesthesiologist, they should
use the surgical or medical code and fee established for that code. Anesthesia
units and conversion factors are to be used only when the primary purpose of
the service is to anesthetize the patient so that the surgical procedure can be
performed.
d. Trigger point
injection is considered one procedure and is reimbursed as such regardless of
the number of injection sites.
B. Reimbursement Guidelines for Anesthesia
Services. Anesthesia services may be billed for any one of the three following
circumstances.
1. An anesthesiologist
provides total and individual anesthesia service.
2. An anesthesiologist directs a
CRNA.
3. Anesthesia provided by a
CRNA working independent of an anesthesiologist's supervision is covered under
all the following conditions.
a. The service
falls within the CRNA's scope of practice and scope of license as defined by
law.
b. The service is reasonable
and medically necessary.
c. The
service is supervised by a licensed health care provider who has prescriptive
authority.
d. The service is
provided under one of the following conditions:
i. in accordance with the clinical privileges
individually granted by the hospital or other health care
organization;
ii. the doctor
performing the procedure requiring the service specifically requests the
service of a CRNA;
iii. the patient
requiring the service specifically requests the service of a CRNA;
iv. the services are provided by a CRNA in
connection with a medical emergency; or
v. no anesthesiologist is on staff or an
anesthesiologist is unable to provide the service.
e. Payment for covered anesthesia services
provided by a CRNA will be limited to the lesser of the actual charge or 80
percent of the medical reimbursement guideline total anesthesia value. Use
Modifier -QZ.
f. Where a single
anesthesia procedure involves both a physician medical direction service and
the service of the medically directed CRNA, the payment amount for the service
of each is 50 percent of the allowance otherwise recognized had the service
been furnished by the anesthesiologist alone.
i. Use Modifier -QX if medical direction by
physician.
ii. Use Modifier -QY if
medical direction for one CRNA by anesthesiologist.
iii. Reimbursement shall not be made to
either the anesthesiologist or the CRNA until the insurer has received and
reviewed the bill and the anesthesia report from both providers.
iv. Reimbursement shall never exceed 100
percent of the maximum amount an anesthesiologist would have been allowed under
the Medical Fee Schedule Allowance had the anesthesiologist or physician alone
performed the services.
v. Medical
supervision, as opposed to medical direction, occurs when the anesthesiologist
is involved in furnishing more than four procedures concurrently or is
performing other services while directing the concurrent procedures. No
additional reimbursement shall be made for general supervisory services
rendered by the anesthesiologist or other physician.
The following
Sections apply to all the schedules mentioned in the beginning of Chapter 51:
§§5119, 5121, 5123, 5145, 5147, 5149, and
5153.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
23:1034.2.
