Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-21 - Anesthesia services
Universal Citation: OH Admin Code 5160-4-21
Current through all regulations passed and filed through September 16, 2024
(A) Scope and definitions.
(1) This rule sets forth provisions governing
payment for the administration or management of anesthesia as a
non-institutional professional service rendered by qualified medical
practitioners. Provisions governing payment for anesthesia as a dental service
are set forth in Chapter 5160-5 of the Administrative Code.
(2) "Base unit" is an anesthesia-related
component representing factors other than an anesthetist's time, such as
standard pre-operative and post-operative visits, the administration of fluids
or blood incident to anesthesia administration, and monitoring.
(3) "Base unit value" is the
value for a base unit assigned by
the
centers for medicare and medicaid services (CMS).
A table of procedure codes and their respective base unit
values is available from the CMS web site,
https://www.cms.gov.
(4)
"Time unit" is an anesthesia-related component representing the span, reported
in minutes, during which an anesthesiologist or a medically-directed or
medically-supervised qualified non-physician anesthetist is continuously
present. The measured length of the time unit depends on the type of
anesthesia.
(a) For neuraxial labor analgesia,
the time unit begins when the analgesic is inserted and ends at delivery. Total
duration is limited to two hundred forty minutes (four hours).
(b) For all other anesthesia, the time unit
begins when the anesthetist starts to prepare the individual for the induction
of anesthesia and ends when the presence of the anesthetist is no longer
required and the individual may be safely placed under post-anesthetic
care.
(5) "Time unit
value" is the number of fifteen-minute increments in a time unit, rounded to
the nearest tenth.
(B) Providers.
(1) Rendering providers. The
following eligible medicaid providers may administer anesthesia:
(a) An anesthesiologist (i.e., a physician
trained in anesthesia);
(b) A
certified registered nurse anesthetist (CRNA); or
(c) An anesthesiologist assistant
(AA).
(2) Billing
providers. The following eligible medicaid providers may receive medicaid
payment for submitting a claim for administering anesthesia:
(a) An anesthesiologist;
(b) A CRNA;
(c) A professional medical group;
or
(d) An AA.
(C) Coverage.
(1) Payment may be made for the following
procedures or activities as anesthesia services:
(a) Procedures performed during a surgical or
diagnostic procedure:
(i) Administration of
general anesthesia;
(ii)
Administration of regional anesthesia;
(iii) Supplementation of local
anesthesia;
(iv) Administration of
post-operative pain block procedures separately from anesthesia;
(v) Provision of monitored anesthesia care
(MAC); and
(vi) Performance of
unusual monitoring procedures such as cardiovascular catheterization (e.g.,
intra-arterial, central venous, Swan-Ganz);
(b) Administration of obstetrical anesthesia
for either of two purposes:
(i) Neuraxial
analgesia for vaginal delivery (including repeated subarachnoid needle
placement, drug injection, and necessary epidural catheter replacement during
labor); or
(ii) Anesthesia for
cesarean delivery; and
(c) Provision of medical direction or
supervision by an anesthesiologist.
(2) No separate payment is made for the
following services, which are considered to be part of anesthesia
administration:
(a) Routine pre-operative and
post-operative visits;
(b)
Anesthesia care during the procedure;
(c) The administration of fluid or blood
products incident to the anesthesia or surgery; and
(d) Usual monitoring procedures (e.g.,
electrocardiography, the taking of body temperature, the recording of blood
pressure, oximetry, capnography, mass spectometry).
(D) Allowances and limitations.
(1) Payment may be made on a case-by-case
basis for two anesthesia services provided to one individual on a single date
of service only if at least one of the following conditions applies:
(a) Between the two surgical or diagnostic
procedures, the individual either was released from the recovery area to the
floor (or intensive care unit) or was discharged from the hospital;
(b) After completion of the surgical or
diagnostic procedure, the individual had to return for a follow-up procedure on
an emergency basis;
(c) It was
medically necessary for two surgical or diagnostic procedures to be performed
separately, and two separate anesthetics were required; or
(d) Anesthesia was administered both for a
delivery and separately for a tubal ligation meeting the requirements specified
in Chapter 5160-21 of the Administrative Code.
(2) In all other cases, payment may be made
only for one anesthesia service provided to one individual on a single date of
service.
(3) Payment for anesthesia
services may be made to an anesthesiologist only if all of the following
conditions are met:
(a) The anesthesiologist
acts exclusively as an anesthetist and does not also act as a surgeon or
assistant surgeon;
(b) The
anesthesiologist completes the following tasks in preparation for anesthesia
administration:
(i) Performing a
pre-anesthetic examination and evaluation or, for obstetrical anesthesia,
performing or approving a pre-anesthetic examination and evaluation for labor
analgesia provided by a qualified anesthetist; and
(ii) Prescribing an anesthesia plan or, for
obstetrical anesthesia, prescribing or approving an anesthesia plan.
(c) For each individual patient,
the anesthesiologist carries out the following activities:
(i) Personally participating in the most
demanding parts of the anesthesia plan, including induction and emergence or,
for obstetrical anesthesia, personally participating in all critical portions
of the procedure (e.g., needle placement for neuraxial analgesia);
(ii) Ensuring that any procedures in the
anesthesia plan that the anesthesiologist does not perform are performed by a
qualified individual;
(iii)
Monitoring the course of anesthesia administration at frequent intervals or,
for obstetrical anesthesia, periodically monitoring the course of anesthesia or
analgesia administration or ensuring that a qualified anesthetist performs the
monitoring;
(iv) Remaining
physically present and available for immediate diagnosis and treatment in case
of emergency or, for obstetrical anesthesia, remaining readily available for
immediate diagnosis and treatment in case of emergency; and
(v) Providing indicated post-anesthetic
care.
(4)
Payment for medical direction may be made to an anesthesiologist if the
anesthesiologist delegates some or all of the activities listed in paragraphs
(D)(3)(b) and (D)(3)(c) of this rule to not more than four qualified
non-physician anesthetists performing concurrent anesthesia
procedures.
(5) Payment for medical
supervision may be made to an anesthesiologist if the following conditions are
met:
(a) For obstetrical anesthesia, the
anesthesiologist delegates some or all of the activities listed in paragraph
(D)(3)(c) of this rule to qualified non-physician anesthetists, and the
anesthesiologist supervises one of the following activities:
(i) A critical portion of more than four
concurrent obstetrical anesthesia procedures (e.g., needle placement for
neuraxial analgesia);
(ii) A
critical portion of an obstetrical anesthesia procedure along with more than
four concurrent surgical anesthesia procedures; or
(iii) A critical portion of an obstetrical
anesthesia procedure while the anesthesiologist is not physically present in
the obstetrical suite.
(b) For all other anesthesia, the
anesthesiologist delegates some or all of the activities listed in paragraph
(D)(3)(c) of this rule to more than four qualified non-physician anesthetists
performing concurrent anesthesia procedures.
(6) In addition to payment for surgical
procedures, a surgeon or a group practice of surgeons is permitted to receive
payment for anesthesia services provided by a CRNA who is employed by the
surgeon or group practice.
(7) The
services of a CRNA or AA employed by a hospital are considered to be hospital
services, payment for which is made to the hospital.
(E) Claim payment.
(1) Payment for an anesthesia service is the
lesser of the provider's submitted charge or the medicaid maximum, which is
determined by a formula.
(a) The amount is the
product of three factors:
(i) The sum of the
base unit value and the time unit value;
(ii) The appropriate conversion factor;
and
(iii) The relevant
multiplier.
(b)
Conversion factors and multipliers are listed in the appendix to this
rule.
(c) For daily management of
epidural or subarachnoid drug administration, the time unit value is
zero.
(2) No additional
payment will be made on account of physical status, age, body temperature
(hypothermia or hyperthermia), emergency conditions, or time of day.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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