According to the American Society of Anesthesiologists’ (ASA) guidelines, anesthesia payments are comprised of three components. These components are as follows:
Basic Value - This element represents the cost of the anesthetic management of the procedure. It includes the cost of all anesthesia services provided, except the actual time spent rendering the anesthesia and/or any payment for complex patient conditions present during the procedure. Examples of services included in this component include pre-operative and post-operative visits, administration of fluids and/or blood products related to the anesthesia care, and interpretation of non-invasive tests. Basic value is stated in terms of anesthesia units;
Modifying Units - Physical status modifiers are used to indicate the patient’s condition at the time of the surgical procedure. These modifiers may increase the provider’s reimbursement by adding additional anesthesia units to the basic value. Additional payment is determined by the complexity of the patient’s medical condition. Regardless of whether or not an increased payment is warranted, a physical status modifier is required on all anesthesia claims. There are other anesthesia modifiers besides those relating to physical status, such as modifiers that qualify whether or not CRNA administered anesthesia was under the direction of a physician. When appropriate, anesthesia providers bill these modifiers in addition to the applicable physical status modifier; and
Time Units - This element represents the specific amount of time required to perform the surgical procedure. Time units are added to the basic value and applicable modifying units to complete the anesthesia payment. Time units are reported as is customary in the provider’s geographic region.
While ASA guidelines do not specify the manner in which time should be indicated, MHP guidelines stipulate the following:
Paper submission: The number of minutes required to complete a surgical procedure must be indicated in field 24g. Time in units is not accepted; and
Electronic submission: The appropriate unit of measure indicator must be submitted. If the time submitted is units, indicator UN is required. If the time submitted is minutes, indicator MJ is required.
Failure to submit claims in the manner indicated above may result in incorrect reimbursement.
Submit claims with the appropriate ASA code for the procedure performed as indicated in the ASA Relative Value Guide, as well as at least one anesthesia modifier. Anesthesia modifiers are limited to the following codes: 23, AA, AD, G8, G9, P1-P6, QK, QS, QX, QY or QZ. (See below for specific information related to modifiers QK, QX, QY and QZ.) In addition, time must always be indicated specifically in total minutes. Time should never be indicated in anesthesia units. For example: if a procedure required an hour and a half of anesthesia time, ”90” should be indicated in field 24g of the CMS1500 form.
Payment for anesthesia services is made according to contracted rates and based on the 'base + time' units as indicated in the ASA Relative Value Guide. Fifteen minutes equals one unit of time. MHP rounds fractional units up or down to the nearest whole unit.
The teaching anesthesiologist should use AA and GC modifiers.
The teaching anesthesiologist should report AA and GC modifiers if involved in training of residents in a single anesthesia case.
The teaching anesthesiologist should also report AA and GC modifiers if involved in two concurrent resident cases.
The teaching anesthesiologist should report AA and GC modifiers if involved in one resident case concurrent to another case paid under the CMS medical direction payment policy.
The GC modifier is reported by the teaching physician to indicate that he/she rendered the service in compliance with the teaching physician requirements.
Charges for anesthesiologists and CRNAs should be billed separately using the appropriate ASA code and modifiers. Charges filed on behalf of the anesthesiologist must include the HCPCS modifier 'QK' which is defined as 'medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals' (i.e. CRNAs). If the anesthesiologist is medically directing only one anesthesia procedure performed by a CRNA, the modifier 'QY' should be used. Concurrently, the claim for the CRNA should include the modifier 'QX' which is defined as 'CRNA service with medical direction by a physician.' If a CRNA must perform anesthesiology services in the absence of an anesthesiologist, only the CRNA’s charges should be submitted and should include the modifier 'QZ.'
Pre- and post-anesthesia consultations or evaluations are part of the global anesthesia reimbursement.
'Qualifying circumstances' (e.g. frail health status, patients under the age of one or over the age of seventy, cancelled surgery) must be billed with the appropriate anesthesia procedure codes (i.e. 99100, 99116, 99135, or 99140).
Anesthesia services are covered under the authorization for the surgery obtained by the physician performing the procedure. No separate authorization is required.
For members of all plans, authorization is required for pain management services performed on an outpatient basis at a participating facility. Post-operative pain management services billed for the same date of service as the surgery must include supporting documentation.
Claims for anesthesia services submitted by the provider who performs the surgical procedure are denied as included in the global rate for the procedure. The member is not responsible for these charges. This does not pertain to oral surgeons or dentists (services are covered for accidental dental only).