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Anesthesia Services

Revised: 11-25-2014

  • • Overview
  • • Eligible Providers
  • • Eligible Recipients
  • • Covered Services
  • • Pre-Anesthetic Evaluations and Post-Operative Visits
  • • Criteria for Medical Direction
  • • Concurrent Medical Direction of CRNAs
  • • Criteria for Supervision
  • • Surgeon Supervision of Anesthesia Services
  • • Monitored Anesthesia Care (MAC)
  • • Moderate Sedation
  • • Deep Sedation
  • • Recipient Controlled Analgesia (During Hospitalization)
  • • Special Services
  • • Billing
  • • Claim Documentation Requirements
  • • Exact Minutes
  • • MHCP Anesthesia Payment Formulas
  • • Modifiers
  • • Payment for Qualifying Circumstances
  • • MAC by an Anesthesiologist
  • • MAC by a CRNA
  • • Conscious Sedation
  • • Deep Sedation
  • • Patient Controlled Analgesia (During Hospitalization)
  • • Epidural Analgesia for Vaginal or Cesarean Delivery
  • • Anesthesia for Ocular Procedures and Pacemakers
  • • Special Services
  • • Inpatient Hospital CRNA
  • • MHCP Enrolled CRNA
  • • Definitions
  • • Legal References
  • Overview

    Anesthesia services are provided to patients undergoing surgical or nonsurgical procedures in an outpatient or inpatient setting where the administration of an anesthetic is required. Reporting anesthesia services is appropriate by or under the responsible supervision of a physician. To provide the recipient the anesthesia care deemed appropriate these services may include, but are not limited to:

  • • General anesthesia
  • • Regional anesthesia
  • • Supplementation of local anesthesia
  • • Other support services
  • These services include:

  • • Preoperative and postoperative visits
  • • Anesthesia care during the procedure
  • • Administration of fluids or blood
  • • Usual monitoring services (ECK, temperature, blood pressure, oximetry, capnography and mass spectrometry)
  • Eligible Providers

  • • Anesthesiologists (MDA)
  • • Certified Registered Nurse Anesthetist (CRNAs). CRNAs must enroll and sign a provider agreement to be eligible for reimbursement
  • • Physicians (MDs) under limited conditions as described in the conscious sedation and deep sedation sections
  • Provider Type Home Page Links
    Review related Web pages for the latest news and additions, forms, and quick links.

    Eligible Recipients

    Recipients undergoing surgical or nonsurgical procedures in an outpatient or inpatient setting where the administration of an anesthetic is required.

    Covered Services

    Pre-Anesthetic Evaluations and Post-Operative Visits

    MHCP uses the Centers for Medicare and Medicaid Services (CMS) list of base values, adopted from the relative base values established by the American Society of Anesthesiologists (ASA). The base value for anesthesia services includes usual pre-operative and post-operative visits. No separate payment is allowed for the pre-anesthetic evaluation regardless of when it occurs unless the recipient is not induced with anesthesia because the surgery was cancelled.

    If an anesthetic is not administered due to a surgery cancellation, the anesthesiologist or independent CRNA may bill an Evaluation and Management (E/M) CPT code that demonstrates the level of service performed.

    Criteria for Medical Direction

    Anesthesiologists can be reimbursed for the personal medical direction, as distinguished from supervision, they furnish to CRNAs.

    MHCP will reimburse medical direction services personally performed by an anesthesiologist only if the anesthesiologist:

  • • Performs a pre-anesthetic examination and evaluation
  • • Prescribes the anesthesia plan
  • • Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence (if applicable)
  • • Ensures any procedures in the anesthesia plan they do not perform are performed by a qualified individual
  • • Monitors the course of anesthesia administration at frequent intervals
  • • Remains physically present in the surgical suite and available for immediate diagnosis and treatment of emergencies
  • • Provides indicated post-anesthesia care
  • If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation, and another may fulfill the other criteria. Similarly, one physician member of the group may provide post anesthesia care, while another member of the group provides the other components of anesthesia services. The medical record must indicate physicians provided the services and identify the physicians who rendered them.

    MHCP will reimburse anesthesiologists for supervision of residents, per Medicare's formula and restrictions. The teaching physician must be present during induction, emergence, and during all critical portions of the procedure and immediately available to provide services during the entire service or procedure. Documentation in the medical records must indicate the teaching anesthesiologist's presence or participation in the administration of the anesthesia. The teaching physician's presence is not required during the pre-operative or post-operative visits with the recipient. MHCP follows Medicare guidelines for reimbursement to anesthesiologists for the supervision of residents.

    MHCP does not reimburse for anesthesia assistants or interns.

    Concurrent Medical Direction of CRNAs

    In all cases where the anesthesiologist provides medical direction, they must be physically present in the operating suite.

    If the anesthesiologist supervises anesthetists during five or more concurrent procedures, payment is made only for patient services personally performed by the anesthesiologist, not to exceed three base units plus 15 minutes for induction.

    Billing or scheduling records that describe the anesthesia services provided must indicate the number of CRNA procedures concurrently medically directed by the anesthesiologist.

    Calculation of Concurrent Medically Directed Anesthesia Procedures
    Concurrency is defined with regard to the maximum number of procedures the anesthesiologist is medically directing within the context of a single procedure and whether or not these other procedures overlap each other. The following table illustrates the concept of concurrency:

    Procedures A through E are medically directed procedures involving CRNAs.
    The starting and ending times for each procedure represent the periods during which "anesthesia time" is counted.

    Procedures

    Time of Total Surgery

    Physician Concurrently Directed Cases

    Concurrently Directed Cases Time Frame

    Number of Directed Surgeries

    A

    8:00-8:20 a.m.

    A & B

    8:10-8:20 a.m.

    2

    B

    8:10-8:45 a.m.

    B & C

    8:20-8:45 a.m.

    2

    C

    8:30-9:15 a.m.

    C, D, & E

    9:00-9:15 a.m.

    3

    D

    9:00-12 noon

    C, D, & E

    9:00-9:15 a.m.

    3

    E

    9:10-9:55 a.m.

    C, D, & E

    9:00-9:15 a.m.

    3

    Criteria for Supervision

    When the anesthesiologist does not fulfill the above criteria or is involved in concurrently supervising more than four procedures, their supervisory services are considered services to the hospital and are reimbursable only to the hospital. MHCP will consider payment for pre-anesthesia services up to and including induction, when personally performed by the anesthesiologist.

    Surgeon Supervision of Anesthesia Services

    MHCP will not reimburse a surgeon for supervision of anesthesia services provided by a:

  • • Anesthesia assistant
  • • CRNA
  • • Intern
  • • Resident
  • Monitored Anesthesia Care (MAC)

    Monitored anesthesia care is a specific anesthesia service where an anesthesiologist or CRNA was requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.

    Monitored anesthesia care includes all aspects of anesthesia care:

  • • Preprocedure visit
  • • Intraprocedure care
  • • Postprocedure anesthesia management
  • During monitored anesthesia care, the anesthesiologist or CRNA must be physically present continuously and provide a number of specific services, including but not limited to:

  • • Monitoring of vital signs, maintenance of the patient's airway and continual evaluation of vital functions
  • • Diagnosis and treatment of clinical problems that occur during the procedure
  • • Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort
  • • Provision of other medical services as needed to accomplish the safe completion of the procedure
  • Anesthesia care often includes the administration of doses of medications where the loss of normal protective reflexes or loss of consciousness is likely. Monitored anesthesia care refers to those clinical situations where the patient remains able to protect the airway for the majority of the procedure. If, for an extended period, the patient is rendered unconscious or loses normal protective reflexes, then anesthesia care is considered a general anesthetic.

    Moderate Sedation

    The intent of conscious sedation is for the recipient to remain conscious and able to communicate during the entire procedure. The recipient retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation or verbal command. Conscious sedation includes:

  • • Performance and documentation of pre-and post sedation evaluations of the recipient
  • • Administration of the sedation or analgesic agents
  • • Monitoring of cardio respiratory functions (pulse oximetry, cardio respiratory monitor and blood pressure)
  • Deep Sedation

    Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but purposefully respond following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.

    Emergency medicine physicians (MDs) whose advance practice training has prepared them for airway management, advanced life support and rescue from any level of sedation may administer deep sedation.

    Recipient Controlled Analgesia (During Hospitalization)

    MHCP covers patient controlled analgesia for pain with the continuous infusion of pain medication facilitated by an infusion pump in a hospital setting.

    MHCP covers medically necessary daily pain management service. The service must be conducted face-to-face.

    Special Services

    MHCP covers specialized services performed by an anesthesiologist or independent CRNA, such as insertion of Swan-Ganz catheters, placement of central venous lines and arterial lines.

    Billing

    Claim Documentation Requirements

    Submit claims for anesthesia services on the 837P. Use the specific CPT ASA anesthesia codes or surgical codes with the appropriate anesthesia modifier. For authorized surgical services, MHCP prefers that anesthesia services are billed using surgical procedure codes with the appropriate anesthesia modifier.

    Anesthesiologists and CRNAs must comply with MHCP requirements for billing sterilization procedures. Submit a Sterilization Consent Form, signed and dated by the recipient and the physician, with anesthesia claims for sterilization procedures. Refer to the Sterilization section of the MHCP Provider Manual for additional information.

    Exact Minutes

    Submit the exact number of minutes from the preparation of the recipient for induction to the time when the anesthesiologist or the CRNA was no longer in personal attendance or continued to be required. Enter only the number of minutes in the MN–ITS Interactive units field on the services tab. MHCP will calculate the base units for each procedure.

    Use the following formula chart to determine the MHCP Anesthesia Payment rate for the current and previous year.

    MHCP Anesthesia Payment Formulas

    2014

    MHCP follows Medicare coverage standards for direction and supervision of CRNAs, SRNA, and anesthesia residents.

    Time units equal the number of minutes from preparation of the patient to the time when the anesthetist is no longer in personal attendance or continues to be required. Time units/15 is truncated at one decimal place. Example: 62/15 = 4.1.

    Modifier

    Description

    2014 Formula

    AA

    Anesthesiologist Personally Performed

    (Base Units + (Time Units / 15)) X 18.00

    AA GC

    Anesthesiologist Directing One Anesthesia Resident or SRNA

    (Base Units + (Time Units / 15)) X 18.00

    QY

    Anesthesiologist Directing One CRNA

    (Base Units+(Time units / 15)) X 21.41 X 0.632

    QK

    Anesthesiologist Directing 2 - 4 CRNA

    (Base Units+(Time units / 15)) X 20.62X 0.632

    QK GC

    Anesthesiologist Directing 2 – 4 Anesthesia Residents or SRNA

    (Base Units+(Time units / 15)) X 21.41 X 0.632

    AD

    Anesthesiologist Supervising More Than Four CRNA

    4 Base Units X 18.00

    QX

    CRNA Directed by an Anesthesiologist

    (Base Units+(Time units / 15)) X 21.41 X 0.632

    QZ

    CRNA Without Direction by an Anesthesiologist

    (Base Units + (Time Units / 15)) X 18.00

    2013

    Modifier

    Description

    2013 Formula

    AA

    Anesthesiologist Personally Performed

    (Base Units + (Time Units / 15)) X 18.00

    AA GC

    Anesthesiologist Directing One Anesthesia Resident or SRNA

    (Base Units + (Time Units / 15)) X 18.00

    QY

    Anesthesiologist Directing One CRNA

    (Base Units+(Time units / 15)) X 20.62 X 0.632

    QK

    Anesthesiologist Directing 2 - 4 CRNA

    (Base Units+(Time units / 15)) X 20.62 X 0.632

    QK GC

    Anesthesiologist Directing 2 – 4 Anesthesia Residents or SRNA

    (Base Units+(Time units / 15)) X 20.62 X 0.632

    AD

    Anesthesiologist Supervising More Than Four CRNA

    4 Base Units X 18.00

    QX

    CRNA Directed by an Anesthesiologist

    (Base Units+(Time units / 15)) X 20.62 X 0.632

    QZ

    CRNA Without Direction by an Anesthesiologist

    (Base Units + (Time Units / 15)) X 18.00

    Modifiers

    Anesthesia Modifiers
    To properly identify the exact nature of the service provided, use the following HCPCS code modifiers

    AA

    Anesthesia services performed personally by anesthesiologist

    AD

    Medical supervision by a physician: more than four concurrent anesthesia procedures

    QK

    Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

    QS

    Monitored anesthesia care services

    QX

    CRNA service with medical direction by an anesthesiologist

    QY

    Anesthesiologist medically directs one CRNA

    QZ

    CRNA service without medical direction by an anesthesiologist

    Q6

    Service furnished by Locum Tenens physician

    22

    Increased procedural services

    Payment for Qualifying Circumstances

    MHCP reimburses anesthesia "for a patient of extreme age" only if the recipient is less than one year of age or over 70 years of age. Bill the anesthesia for a recipient of extreme age code on a separate line and bill for one unit. Do not use anesthesia modifiers.

    MAC by an Anesthesiologist

    Monitored anesthesia care is a covered service if the anesthesiologist performs the services. The time the anesthesiologist is physically present with the recipient is covered.

    An anesthesiologist may not bill for monitoring time not spent in direct contact with the recipient. Use the appropriate anesthesia or surgical procedure code to bill this service and indicate the exact number of minutes in direct contact. If the anesthesiologist is billing for medical direction, the anesthesiologist must meet the criteria for medical direction. Modify the procedure code to indicate whether the service was done under medical direction or personally performed. Indicate QS as the secondary modifier.

    MAC by a CRNA

    Monitored anesthesia care is a covered service if the CRNA performs the services. The time the CRNA is physically present with the patient is covered. Use the appropriate anesthesia or surgical procedure code to bill this service and indicate the exact number of minutes in direct recipient contact. Modify the procedure code indicating the service was done under medical direction or independently performed. Indicate QS as the secondary modifier.

    Conscious Sedation

    Conscious sedation may be administered by physicians (MDs) trained in moderate sedation. Follow current CPT guidelines for the use of conscious sedation codes. Conscious sedation codes cannot be billed when anesthesia services are provided at the same time.

    Deep Sedation

    Use the appropriate anesthesia or surgical procedure code to bill deep sedation and indicate the exact number of minutes in direct recipient contact. When deep sedation is performed by emergency medicine physicians, add modifier AA to the procedure code.

    Patient-Controlled Analgesia (During Hospitalization)

    MHCP will separately reimburse the placement of an intrathecal or epidural catheter. Bill the correct unmodified CPT surgical procedure for the catheter placement. Do not bill the placement of the catheters with time units or with anesthesia modifiers.

    Use the appropriate CPT code to bill this service. This service is not billed in units of time, and is limited to one service per day.

    Epidural Analgesia for Vaginal or Cesarean Delivery

    The CPT code that describes the service of continuous epidural analgesia for labor and vaginal or cesarean delivery includes the placement of the epidural catheter. Do not separately bill the placement of the epidural catheter. Indicate the number of minutes in the MN–ITS Interactive units field on the services tab the anesthesiologist or CRNA is physically present with the recipient.

    See the User Guide (PDF) for more detailed information.

    Anesthesia for Ocular Procedures and Pacemakers

    Anesthesia policy for ocular and pacemaker surgery follows Medicare guidelines.

    Special Services

    Bill these services with the appropriate unmodified CPT codes that describe the services. Bill the services as surgical procedures and no time units.

    Inpatient Hospital CRNA

    Inpatient CRNA services must be separately billed on an 837P. Refer to Hospital Services for additional billing information.

    MHCP Enrolled CRNA

    Bill for MHCP-enrolled CRNA services provided in an outpatient hospital setting by any of the following on the 837P:

  • • A CRNA independent or employed by a physician
  • • A CRNA employed by a hospital
  • • An entity or group not enrolled as a hospital that is billing CRNA services
  • • A CAH that does not qualify for the CRNA billing exemption under Medicare Part B
  • See the User Guide (PDF) for more detailed information on billing for CRNAs who are employees or independent CRNAs.

    Definitions

    Anesthesiology: The practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during and after surgery.

    Anesthesiologist: A physician who specializes in anesthesiology and is board certified as an anesthesiologist.

    Certified Registered Nurse Anesthetist (CRNA): An advance practice registered nurse. CRNAs are registered nurses with a baccalaureate degree who have completed an additional 24 to 36 months of training in anesthesiology in an accredited program and are certified by the Council on Certification of Nurse Anesthetists, or the Council on the Certification of Nurse Anesthetists of the American Association of Nurse Anesthetists (AANA).

    Personally Performed: To be considered personally performed, the anesthesiologist may not be involved in any other procedure or duties that take them out of the operating room. It will be assumed that if the anesthesiologist leaves the operating room, they were performing other duties. If the anesthesiologist leaves the operating room to perform any other duties, the anesthesia procedure may not be billed as personally performed.

    Physician: A medical doctor (MD) who is licensed to provide health services within the scope of his/her profession under MS 147.

    SRNA: Student Registered Nurse Anesthetist.

    Legal References

    Minnesota 2009 Session Law, Chapter 79, article 5, section 25 Physician rates for direction of CRNA
    Minnesota 2009 Session Law, Chapter 79, article 5, section 28 CRNA rates not directed by physician
    Minnesota Statutes 147

    Minnesota Statutes 256B.0625
    , subd.3; subd. 11

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