ANESTHESIA REIMBURSEMENT METHODOLOGY
Code Description Comments
01960 Anesthesia for vaginal delivery only Bill when no neuraxial/anesthesia is involved with vaginal delivery; not reimbursed with 01967
01961 Anesthesia for Cesarean delivery only Use to report anesthesia services for a planned cesarean section; not reimbursed with 01968
01967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery Time unit cap limits apply; use to report epidural labor and vaginal delivery
01968 Anesthesia for cesarean delivery following neuraxial labor/anesthesia Must be reported in addition to 01967; use to report when a planned vaginal delivery turns into a cesarean section; not reimbursed when billed alone; this code in combination with 01967, is subject to the cap limits for C-sections (e.g., 01967 billed with 01968 is subject to a combined cap limit of 270 minutes)
01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia Must be reported in addition to 01967; not reimbursed when billed alone
EFFECTIVE FOR DATES OF SERVICES ON AND AFTER 10/01/03
Maternity CPT Codes 01961, 01967, 01968, and 01969 The Division of Medicaid has authorized modifications to the methodology for reimbursing maternity anesthesia on certain codes. Effective retroactively for dates of services on and after October 1, 2003, the reimbursement for CPT Code 01961, 01967, 01968, and 01969 will be fee for service (flat fee). Providers must note that CPT Codes 01968 and 01969 are add on codes and must be billed with CPT 01967.
CPT Code 01961 ……….. $372.29
CPT Code 01967…………$402.82
CPT Code 01968…………$124.60 (Add on code which must be billed with CPT 01967)
CPT Code 01969…………$207.67 (Add on code which must be billed with CPT 01967)
All claims previously submitted with CPT Codes 01961, 01967, 01968, and 01969 with dates of services on and after October 1, 2003 will be voided by the Fiscal Agent, ACS. After the provider receives a remittance advice showing the voided claim, the provider may then resubmit the claim to be reimbursed fee for service. When billing for these codes, the provider must always report one (1) unit in field 24G of the CMS 1500 claim form.
The 5% reduction authorized by House Bill 1200 in the 2002 legislative session will be applied to the fee.
Coding Guidelines for Bilateral Tubal Ligation or Urgent Hysterectomy Following Delivery
A bilateral tubal ligation (BTL) is performed following vaginal delivery where regional anesthesia was utilized for the labor and delivery.
An urgent hysterectomy is performed following delivery.
The provider will bill for both the labor epidural/delivery (CPT 01967) and the BTL (CPT 00851 or urgent hysterectomy (CPT 01962).The first (labor epidural /delivery – flat fee) will end and the second procedure (BTL or urgent hysterectomy- base plus time reimbursement) will begin utilizing the following criteria:
(A) If the delivery occurs in a different room and table than where the BTL procedure or urgent hysterectomy will be performed, the anesthesia start time on the second procedure begins when the patient is moved on to the operation table for the BTL procedure or urgent hysterectomy.
(B) If the delivery occurs in the same room and table where the BTL procedure or urgent hysterectomy will be performed, the anesthesia start time will begin when the surgical nurse begins to prepare the patient for the BTL procedure or urgent hysterectomy.
Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969
When a primary OB delivery anesthesia procedure (01967) is billed with either 01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.
Reimbursement for regional anesthesia, may include any one of the following procedures:
|Nerve Blocks||A nerve block involves the injection of a peripheral nerve into or around a given site. If the anesthesiologist administers the injection or block postoperatively in an area separate from the operating room as part of the anesthesia time, additional time required for the injection may be included in the total number of anesthesia minutes reported. If a qualified anesthesia provider remains with the patient, the time should be reported as continuous rather than discontinuous.|
|Spinal, Subarachnoid or Subdural Anesthesia||Spinal, subarachnoid and subdural anesthesia involves the injection of anesthetic or narcotic drugs into the spinal cord. When performed as the primary type of anesthesia, the time required is included in the total anesthesia minutes reported.|
|Epidurals||Epidural analgesia involves the administration of a narcotic drug through an epidural catheter. When performed as the primary type of anesthesia, the time required is included in the total anesthesia minutes reported.|
Labor Epidurals Anesthesia for labor epidurals are time based services and should be billed as total minutes. – 01967: Vaginal delivery with epidural for pain management. Code may be reported as a single anesthesia service. Depending on the terms of the participating provider agreement, reimbursement may be based on base units plus time units (insertion through delivery) subject to a cap of 7 hours or 420 minutes. – 01968: Cesarean delivery following failed attempt at vaginal delivery. This is an add-on code and should always be reported with 01967. – 01969: Cesarean delivery followed by a cesarean hysterectomy after failed planned vaginal delivery. This is an add-on code and should always be reported with 01967.
Procedure codes in the Anesthesia Obstetric section are to be used by anesthesiologists and CRNAs to bill for maternity-related anesthesia services. The delivering physician should use Procedure codes in the Surgery Maternity Care and Delivery section of Procedure to bill for maternity-related anesthesia services. Reimbursement for these services shall be flat fee except for general anesthesia for vaginal delivery.
The following chart is an explanation of the billable modifiers used for maternity-related anesthesia, the Louisiana Medicaid billing definitions, and the provider type that may bill using the modifier.
Modifier Provider Type
That May Bill Billing Definition
AA Anesthesiologist Anesthesia services performed personally by the anesthesiologist
QY Anesthesiologist Medical direction* of one CRNA
QK Anesthesiologist Medical direction of two, three, or four concurrent anesthesia procedures
QX CRNA CRNA service with medical direction by an anesthesiologist
QZ CRNA CRNA service without medical direction by an anesthesiologist
Physician Anesthesia provided by delivering physician 52 Delivering Physician or Anesthesiologist Reduced services
QS** Anesthesiologist or CRNA Monitored Anesthesia Care Service
*Medical direction – explanation can be found after the Surgical Anesthesia section.
** The QS is a secondary modifier only, and must be paired with the appropriate anesthesia provider modifier (either the anesthesiologist or the CRNA). The -QS modifier indicates that the provider did not introduce the epidural catheter for anesthesia, but did monitor the patient after catheter placement.
Billing Add-on Codes for Maternity-Related Anesthesia:
• When an add-on code is used to fully define a maternity-related anesthesia service, the date of delivery should be the date of service for both the primary and add-on code.
• An add-on code in and of itself is not a full service and cannot be reimbursed separately to different providers.
• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.
Billing for Maternity-Related Anesthesia
Use the following chart when:
Anesthesiologist performs complete service, or just supervision of CRNA;
CRNA performs complete service with or without supervision by anesthesiologist.
TYPE OF ANESTHESIA Procedure CODE MODIFER TIME REIMBURSEMENT
Vaginal Delivery General Anesthesia 01960 Valid Modifier Record Minutes Formula
AA or QZ $324.00
QK or QY $162.00
Epidural for Vaginal Delivery 01967 QX Record Minutes $162.00 AA or QZ $403.76 QK or QY $201.88
Cesarean Delivery, only (epidural or general) 01961 QX Record Minutes $201.88 AA or QZ $324.00 $79.76 QK or QY $162.00 $39.88
Cesarean Delivery after Epidural, for planned vaginal delivery 01967 + 01968 QX Record Minutes $162.00 $39.88 AA or QZ $324.00 $79.76 QK or QY $162.00 $39.88
Cesarean Hysterectomy after Epidural and Cesarean Delivery 01967 + 01969 QX Record Minutes $162.00 $39.88
Anesthesia for Tubal Ligation or Hysterectomy
• Anesthesia reimbursement for tubal ligations and hysterectomies is formula-based with the exception of anesthesia for cesarean hysterectomy (code 01969).
• The reimbursement for code 01967 and code 0 969 when billed together will be a flat sum of $403.76. Code 01968 is implied in code 01969 and should not be placed on the claim form if a cesarean hysterectomy was performed after C-section delivery.
• Anesthesiologists and CRNAs must attach Form 96, or OMB No. 0937-0166, “Consent to Sterilization”, to their claims for reimbursement of a sterilization procedure, and Form 96- A, “Acknowledgement of Receipt of Hysterectomy Information”, to their claims for reimbursement of a hysterectomy.
Payment for anesthesia services is based on the sum of an anesthesia code-specific base unit value plus anesthesia time units multiplied by the locality-specific anesthesia conversion factor. Under current policy, if the physician is involved in multiple anesthesia services for the same patient during the same operative session, payment is based on the base unit assigned to the anesthesia service having the highest base unit value and anesthesia time that encompasses the multiple services. The physician reports the anesthesia procedure with the highest base unit value with the multiple procedures modifier, “51”, and total time across all surgical procedures.
The Current Procedural Terminology includes new add-on-codes for anesthesia involving burn excisions or debridement and obstetrical anesthesia. The add-on code is billed in addition to the primary anesthesia code. In the burn area, code 01953 (1 base unit) is used in conjunction with code 01952 (5 base units). In the obstetrical area, code 01968 (2 base units) is used in conjunction with code 01967 (5 base units); code 01969 (5 base units) is used in conjunction with code 01967 (5 base units). The physician reports the add-on-code with the primary anesthesia code. Pricing Claims
Anesthesia add-on-codes are priced differently than multiple anesthesia codes.
Generally, for an add-on code, allow only the base unit of the add-on code. All anesthesia time should be reported with the primary anesthesia code. There is an exception for obstetrical anesthesia.
We have learned that third party payers may have different policies for payment of time units for obstetrical anesthesia than for other anesthesia codes. If the time of the add-on obstetrical codes, such as 01968 or 01969, were reported with the primary code, the time units of the add-on code might be undervalued. To prevent this result, we are requiring, for the obstetrical add-on codes, that the anesthesia time be separately reported with each of the primary and the add-on code based on the amount of time appropriately associated with either code. Thus, recognize both the base unit and the time units for the primary and the add-on obstetrical anesthesia codes.
If your system cannot do this currently, then manually price these claims. The situations involving the add-on-codes are low volume codes for the Medicare population.
EXAMPLE: Code 01967 is billed with 01968. Make two separate calculations. Price code 01967 using 5 base units and anesthesia time units and price code 01968 using 2 base units and anesthesia time units.
Obstetric Anesthesia Services
Neuraxial Labor Analgesia Reimbursement Calculations Consistent with a method described in the ASA RVG® UnitedHealthcare Community Plan will reimburse neuraxial labor analgesia (CPT code 01967) based on Base Unit Value plus Time Units Obstetric Add-On Codes:
Obstetric Anesthesia often involves extensive hours and the transfer of anesthesia management to a second physician. Due to these unique circumstances, UnitedHealthcare Community Plan will consider for reimbursement add-on CPT codes 01968 and 01969 when reported by the same or different individual physician or healthcare professional than reported the primary CPT code 01967 for services rendered to the same individual member.
Louisiana (LA) Medicaid allows reimbursement for a shared obstetric (OB) anesthesia service when the introduction of the anesthesia and the monitoring of the anesthesia are performed by different individual providers (same or different TIN). Claims for CPT codes 01961, 01967, and/or 01968 appended with the specified modifiers in the first and second positions, as shown below, should not deny as duplicate.
Q: CPT code 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery) is performed by an anesthesiologist for a single anesthetic administration. CPT code 00851 (Anesthesia for intraperitoneal procedures in the lower abdomen including laparoscopy; tubal ligation/transection) is subsequently performed by the same anesthesiologist during a separate operative session with a single anesthetic administration on the same date of service for the same patient. How should the anesthesia services be reported?
A: Report CPT code 01967 with the appropriate anesthesia modifier and time. Report CPT code 00851 with the appropriate anesthesia modifier and time and in addition, the appropriate modifier 59, 76, 77, 78, 79, or XE to indicate the anesthesia management service was separate and subsequent to the original anesthesia management service reported with CPT code 01967.
Billing for labor and delivery
Providers should bill ASA code 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes the repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)) for labor and delivery when epidural is used. Providers may bill for a maximum of 180 minutes (three hours).
If labor results in a Cesarean section, add-on code 01968 (Cesarean delivery following neuraxial labor analgesia/anesthesia) should be added. Providers should bill for the time of the Cesarean section portion of the service only. A base of 5 units is added for the ASA code 01967, and a base of 3 units is added for 01968.
For all other labor and delivery, ASA codes 01960 (Anesthesia for vaginal delivery only) and code 01961 (Anesthesia for Cesarean delivery only) should be used.
Providers who bill other CPT codes for additional procedures performed during anesthesia administration must use the units field to indicate the number of times the procedure was performed.
Providers should not include the Basic Unit Value listed in the ASA Manual as part of the units billed.
A provider who bills 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) should bill one unit. Billing the Basic Unit Value of four would indicate placement of four catheters. Reimbursement is based on capped fee schedule.