How to eliminate anesthesia claims filing errors

The following information is to provide awareness and clarification to providers and billers of Anesthesia services to eliminate claim filing errors.

In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.

Coverage of Monitored Anesthesia Care (MAC)

During monitored anesthesia care (MAC), close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.

The following requirements for this type of anesthesia should be the same as for general anesthesia with regard to:

Ø  The performance of preanesthetic examination and evaluation.

Ø  The prescription of the anesthesia care required.

Ø  The completion of an anesthesia record.

Ø  The administration of necessary medications and the provision of indicated postoperative anesthesia care.

For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.

The presence of an underlying condition alone, as reported by an ICD-9-CM diagnosis code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.

Therefore, in cases were the anesthesia is usually provided by the attending surgeon and are included in the global fee and are not separately billable, MAC provided by anesthesia personnel may be necessary due to active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications.

If this is your case, the use of anesthesia modifiers is required as follows:

ü  G8 anesthesia modifier – used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only:  00100, 00300, 00400, 00160, 00532 and 00920.

ü  G9 anesthesia modifier – represents “a history of severe cardiopulmonary disease” and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.

Additionally, anesthesia physical status modifiers must be appended to indicate the clinical condition of the patient receiving MAC: 

P1 – healthy individual with minimal anesthesia risk, 

P2 – mild systemic disease, 

P3 – severe systemic disease with intermittent threat of morbidity or mortality, 

P4 – severe systemic illness with ongoing threat of morbidity or mortality, 

P5 – premorbid condition with high risk of demise unless procedural intervention is performed.

Special conditions and/or criteria must be supported by documentation in the medical record.

Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic.

Documentation requirements

Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the patient’s condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated or markedly invasive).

The medical record should include a pre-anesthesia evaluation including a history and physical exam.

The medical record should include evidence of continuous monitoring of the patient’s oxygenation, ventilation, circulation and temperature.

The medical record should include a post-anesthesia evaluation of the patient including any unusual events or complications and the patient’s status on discharge.

Billing Tips

Anesthesia for Multiple Surgeries
Payment may be made for the anesthesia services provided during multiple or bilateral surgery procedures. When billing anesthesia services associated with multiple or bilateral surgeries, report only the anesthesia procedure with the highest base unit. Report the total time in minutes for all procedures on one detail line item.

Administration of Anesthesia by the Surgeon
Reimbursement for anesthesia performed by the operating surgeon is included in the allowance of the surgical procedure rendered during the same operative session. Separate payment is not allowed when surgeon performs the surgical procedure and performs local or surgical anesthesia.
No claim should be submitted for the anesthesia service.

Anesthesia Time

Anesthesia time begins when the anesthesiologist starts to prepare the patient for the procedure. Normally, this service takes place in the operating room, when monitoring start. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

Anesthesia unit calculation

To calculate the amount of anesthesia units, divide the total anesthesia time in minutes by 15.

Time in Minutes	Anesthesia units
1-15	1
16-30	2
31-45	3
46-60	4

 

**Note: If the surgery is non-covered, the anesthesia is also non-covered**

 Source: Medicare Claims Processing Manual, Chapter 12, Section 50(e) and Medicare Local and National coverage determination.