General Anesthesia Reimbursement Limitations – Medical insurance

Duplicate Billing Not Allowed

Medi-Cal policy prohibits payment for duplicate services and/or billings.  The second and subsequent claims for anesthesia services billed for the same date of service, the same recipient and the same procedure submitted by the same or different providers will be denied with RAD code 328, “Another procedure with an anesthesia modifier has been previously paid for the same recipient on the same date of service.”

Anesthesia Pump Assembly and Operation

The assembly and operation of a pump with oxygenator or heat exchanger (CPT-4 codes 99190 – 99192) is not separately reimbursable by Medi-Cal.   Payment for assembly and operation of such pumps by hospital technicians is included in the reimbursement to the hospital.

General Anesthesia Reimbursement Limitations

Claims billed for reimbursement of the following procedure code/modifier combinations will be denied if claims for a five-digit CPT-4 anesthesia code with anesthesia modifiers -P1; -P3; -P4; -P4 with
ICD-9 diagnosis code 995.89; -P5; -P5 with -ET; or -ZA through -ZG have already been paid to the same provider, for the same recipient and date of service.

    CPT-4 Code    Used With Modifier

    94680, 94681, 94760,    Split billing modifier

    If a provider has been paid for a code/modifier combination listed above and subsequently bills for a procedure using a five-digit CPT-4 anesthesia code and anesthesia modifier, the claim will be reduced by the amount previously paid for the same recipient on the same date of service.  For additional information, refer to Anesthesia Guidelines in the Current Procedural Terminology – 4th Edition.

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