Anesthesiologists are NOT required to request prior authorization. The surgeon must obtain prior authorization when required for procedures identified in the Medical and Surgical Procedure Code List included with the Utah Medicaid
Provider Manual for Physician Services.
The anesthesiologist is required to enter the prior authorization number obtained by the surgeon for the CPT code when billing an ASA code related to a CPT procedure for a hysterectomy, sterilization or abortion. The ASA procedure codes listed below are associated with surgical codes that may require prior authorization by Medicaid.
If federal requirements for obtaining prior authorization for a hysterectomy, sterilization or abortion are not met,Medicaid cannot reimburse either the physician or the anesthesiologist. Exceptions (to the requirement that the surgeon obtain Prior Authorization before the procedure is performed) can
be considered ONLY under one of the following circumstances:
1. The procedure was performed in a life-threatening or justifiable emergency situation.
2. Medicaid is responsible for the delay in prior authorization.
3. The patient is retroactively eligible for Medicaid.
Retroactive authorization for services related to these exceptions may be granted “after-the-fact” with appropriate documentation and review. If approved, the associated ASA code may also be reimbursed.
For additional information about the prior authorization process, refer to the Utah Medicaid Provider Manual, SECTION I, or contact Medicaid Information.
ASA Codes Associated with CPT Codes That May Require Prior Authorization
00402 Anesthesia for reconstructive breast procedures (reduction, augmentation, muscle flaps)
00580 Anesthesia for heart transplant or heart-lung transplant
00796 Liver transplant (recipient)
00840 Anesthesia for intraperitoneal procedures in lower abdomen (hysterectomy and sterilization)
00846 Anesthesia for radical hysterectomy
00848 Anesthesia for pelvic exenteration
00855 Anesthesia for cesarean hysterectomy
00922 Anesthesia for seminal vesicles
00926 Male, external genitalia; radical orchiectomy, inguinal
00928 Anesthesia for inguinal orchiectomy
00932 Anesthesia for complete amputation of penis
00934 Anesthesia for radical amputation of penis with bilateral inguinal lymphadenectomy
00936 Anesthesia for radical amputation of penis with bilateral inguinal and iliac lymphadenectomy
00940 Anesthesia for abortion procedures
00944 Anesthesia for vaginal hysterectomy
00952 Anesthesia for hysteroscopy
Concurrent Medically Directed Anesthesia Procedures
Concurrent Medically Directed Procedures
Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether the other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and one Medicare patient, this represents three (3) concurrent cases.
The following example illustrates this concept and guides physicians in determining how many procedures are directed:
Procedures A through E are medically directed procedures involving CRNAs. The starting and ending times for each procedure represent the periods during which anesthesia times are counted.
Procedure A begins at 8:00AM and ends at 8:20AM
Procedure B begins at 8:10AM and ends at 8:45AM
Procedure C begins at 8:30AM and ends at 9:15AM
Procedure D begins at 9:00AM and ends at 12:00 noon
Procedure E begins at 9:10AM and ends at 9:55AM
Procedure Number of Concurrent Medically Directed Procedures Base Unit Reduction Percentage
A 2 10%
B 2 10%
C 3 25%
D 3 25%
E 3 25%
A physician who is concurrently directing the administration of anesthesia to not more than four (4) surgical patients cannot ordinarily be involved in rendering additional services to other patients. However, addressing an emergency of short duration in the immediate area,administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to the surgical patients.
It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.
However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature. No fee schedule payment is made.
The examples listed above are not intended to be an exclusive list of allowed situations. It is expected that the medically-directing anesthesiologist is aware of the nature and type of services he or she is medically directing, and is personally responsible for determining whether his supervisory capacity would be diminished if he or she became involved in the performance of a procedure. It is the responsibility of this medically-directing anesthesiologist to provide services consistent with these regulations.
