PAYMENT AND REIMBURSEMENT
Reimbursement Methodology for Anesthesia Services
IHCP pricing calculation for anesthesia CPT codes 00100 through 01999 is as follows:
+ Time Units
+ Additional Units for age (if applicable)
+ Additional Unit for emergency or other qualifying circumstances (if applicable)
+ Additional Units for physical status modifiers (as applicable)
× Anesthesia Conversion Factor
= Anesthesia Reimbursement Rate
Medical Direction and CRNA Billing and Reimbursement Requirements
Anesthesia services that are medically directed by an anesthesiologist are priced at 30% of the allowed rate. Anesthesia services that are rendered by a CRNA are priced at 60% of the allowed amount. CRNAs must bill using the procedure codes listed on the Procedure Code Set for Certified Registered Nurse Anesthetists (Specialty 094) table in Anesthesia Services Codes on the Code Sets page at indianamedicaid.com.
Anesthesia procedure code modifiers listed in Table 2 must be used to identify services rendered by CRNAs not enrolled in the IHCP and the anesthesiologist providing medical direction. CRNAs billing with their individual rendering NPI do not need to use modifiers listed in Table 2.
Note: CRNA providers use the same physical status modifiers that apply to the anesthesiologist.
Anesthesia Procedure Code Modifiers for Unenrolled CRNAs and Medical Direction
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QX CRNA with medical direction by a physician
QZ CRNA without medical direction by a physician
Payment at Personally Performed Rate
The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.
Payment at Medically Directed Rate
When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.
These services are to be billed as follows:
1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.
Payment at Non-Medically Directed Rate
In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.
These services are to be billed as follows:
1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.
Payment at Medically Supervised Rate
Only three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised.
Monitored Anesthesia Care
The IHCP allows payment for medically reasonable and necessary monitored anesthesia care (MAC) services on the same basis as other anesthesia services. To identify the services as MAC, providers must append an appropriate modifier to the appropriate CPT code, in addition to other applicable modifiers.
Appropriate MAC modifiers include the following:
• QS – Monitored anesthesia care services
• G8 – Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
• G9 – Monitored anesthesia care (MAC) for a patient who has a history of severe cardiopulmonary condition
MAC also includes the performance of a preanesthestic examination and evaluation; prescription of the anesthesia care required; administration of any necessary oral or parenteral medications, such as Atropine, Demerol, or Valium; and the provision of indicated postoperative anesthesia care.
Reimbursement for Medical Direction of CRNA Services by an Anesthesiologist
• Anesthesiologist services billed with modifier QK, reporting the supervision of two to four CRNAs, are reimbursed at 50 percent.
• Anesthesiologist services billed with modifier AD, reporting the supervision of more than four CRNAs, where the anesthesiologist is not present at the time of induction, are paid as follows: (3 base units + time units) x 50%. When the anesthesiologist is present for induction, an additional time unit is paid when supporting documentation is submitted. Reimbursement is as follows: (3 Base + time units + 1 time unit for induction) x 50%.
• Anesthesiologist services billed with modifier QY reporting the supervision of one CRNA are reimbursed at 50 percent. Note: When an anesthesiologist, employing a CRNA, bills for anesthesia services, the anesthesiologist and CRNA are both reimbursed at 50 percent.
All anesthesia services are reported by use of the anesthesia fivedigit procedure code (00100–01999) plus the addition of a physical status modifier as outlined above. The added units for each physical status modifier are listed in the table in the physical status modifier section above. It may be necessary to further modify listed services using CPT or HCPCS Level II modifiers. These modifiers indicate a service or procedure performed has been altered by some specific
circumstance but has not changed its definition or code. The modifying circumstance shall be identified by the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. If more than one modifier is used, place the “Multiple Modifiers” code 99 immediately after the procedure code. This indicates that one or more additional modifier codes will follow. Only certain modifiers in each of the categories (Evaluation and Management, Anesthesia, Surgery, Pathology/Laboratory, Radiology, General Medicine, and Physical Medicine) will be recognized for reimbursement purposes.
The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers’ compensation billing shall use only the modifiers set out in the Medical Fee Guideline.
Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia. Note: Modifier 47 would not be used as a modifier for the anesthesia procedures 00100–01999. The operating surgeon should report the surgical procedure 10021–69990 with modifier 47 appended when billing for anesthesia services.
Anesthesia Services performed personally by the anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist. Claims submitted with modifier AA are reimbursed at 100 percent
Physical Status Modifiers
Six levels of physical status modifiers are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included to distinguish between various levels of complexity of the anesthesia service provided. A listing of physical status modifiers and the modifying units associated with each is provided in Subsection A, Payment Ground Rules for Anesthesia Services.