Anesthesia

Anesthesia

Anaesthesia is a state of temporary induced (Drug/Gas) loss of sensation or awareness. The CPT code range from 00100 – 01999 plus “Anaesthesia modifier”.  

An Anaesthesiologist, Anaesthesia assistant or qualified non-physician anaesthetist can provide Anaesthesia service.

Types of Anaesthesia:-

These different kinds of Anaesthesia include the following: 
General Anesthesia
Regional Anesthesia - Including Epidural, Spinal and Nerve Block Anaesthesia
Combined General and Epidural Anesthesia
Monitored Anesthesia Care with Conscious Sedation

1. General Anesthesia

During General Anaesthesia, medications are given so patients are unconscious (“asleep”) and unable to feel any pain during the surgical procedure. Some of these medications are given through an IV and others are gases administered through a breathing mask or tube with oxygen.  Some of the side effects of general anaesthesia include nausea, vomiting, sore throat, muscle aches, shivering and confusion. General anaesthesia is the most common type of aesthetic administered.  

2. Regional Anesthesia

Regional Anesthesiology entails injecting a local anesthetic near nerves to numb a portion of the body.  There are several types of regional anesthetics including spinal anesthesia, epidural anesthesia and various specific nerve blocks.  When Regional Anesthesia is used, patients  may be awake, sedated  or put to sleep for their surgical procedure.  

Epidural Anesthesia involves the injection of a local anesthetic, usually with a narcotic, into the epidural space, through either a needle or catheter. The epidural space is outside of the spinal cord. This type of anesthesia is commonly used in labor and delivery and for procedures of the lower extremities.

 

Spinal Anesthesia also involves the injection of a local anesthetic, with or without a narcotic, into the fluid that surrounds the spinal cord. This type of anesthesia is commonly used for genitourinary procedures, cesarean sections and procedures of the lower extremities.

 

Nerve Blocks are used to block pain at a specific site. By injecting a local anesthetic into or around a specific nerve or group of nerves, pain relief can be localized to the site of pain. This type of anesthesia provides pain control during and after a procedure, It is associated with minimal side effects. Examples of nerve blocks include an adductor canal nerve block for knee surgery, an interscalene nerve block for shoulder surgery, and a supraclavicular nerve block for arm surgery. 

These below are the examples for Peripheral block usually performed:-

Interscalene regional block
Supraclavicular block
Axillary block 
Lumbar plexus block

Femoral nerve block
Sciatic nerve block
Popliteal nerve block

3. Combined General with Epidural Anesthesia

This is a combination technique that puts you to sleep and provides pain control, not only during the procedure, but afterwards as well. The placement of the epidural catheter allows for you to have continued pain relief after surgery, which will help you sleep and to move more comfortably after surgery. This type of anesthesia is commonly used for major abdominal and thoracic (chest) procedures. The epidural catheter may be left in place for several days after your surgery.
 
4. Monitored Anesthesia Care with Conscious Sedation

Monitored Anesthsia Care involves the injection of medications through an IV catheter to help you relax, as well as to block pain. A combination of sedative and narcotic medications are used to help you tolerate a procedure that otherwise would be uncomfortable. In addition, the surgeon may inject a local anesthetic at the site of the procedure for pain control. With this type of anesthesia, you are able to respond to questions, but will be drowsy throughout the procedure. Please keep in mind that if for any reason you are unable to tolerate this type of anesthetic, there may be a need for a general anesthetic to be administered to complete the procedure safely.

Important Abbreviations:

CRNA: Certified registered nurse anesthetist
SRNA: Student registered nurse anesthetist
AA: Anesthesiology assistant
MAC: Monitored anesthesia care

Included services:

Preoperative & Postoperative care
Administration of fluids and/or Blood
Monitoring services (Eg: BP, Temperature, ECG, Oximetry, Mass Spectrometry, and Capnography
Laryngoscopy (31505, 31515, 31527)
Bronchoscopy (31622, 31645, 31646)
Introduction of needle or catheter (3600036015)
Venipuncture or transfusion (3640035440)
Blood sample procurement through existing lines
Otorhinolaryngologic services (9251192520, 92543)
CPR (92950)
Temporary transcutaneous pacemaker (92953)
Cardioversion (92960)
ECG/EKG (93000-93010)
Cardiovascular Stress Tests (9301593018)

Excluded services :

The below Monitoring services are separately billable

Areterial line
Central line
Swan-Ganz
TEE
Postoperative pain blocks

Anesthesia coding Guidelines:

Select the appropriate CPT code for the surgical procedure performed, and then select the appropriate ASA crosswalk code.
Select the base unit and time unit.

Select the appropriate modifier to identify the anesthesia provider.
Assign the appropriate Physical status modifier
Assign the appropriate qualifying circumstances codes if applicable.

How to calculate the Anesthesia Service for reimbursement is given below, 
(Base unit + Total Time unit+ Modifying Units) x Conversion Factor = Allowance

Anesthesia Base Unit:

Base units are assigned to anesthesia CPT codes by the CMS. Base units are determined based on complexity of the procedures. Easier the case it’s less base unit and difficult cases have high base unit.

Multiple procedures at same session:

If multiple surgical procedures are performed during a single anesthesia administration, then only the highest base unit value CPT code should be reported. But the total time spent for all procedures would be considered for Anesthesia Time unit.

Anesthesia Time Unit:

1.   Start Time: The anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room.  (Note: reviewing Medical Record before surgery is not considered)

2.   End Time: The anesthesiologist is no longer in personal attendance; patient may be safely placed under postoperative supervision.  

Time of anesthesia is calculated in units (Each 15 min = 1 unit)

Total anesthesia time should be recorded in minutes. Each 15 min is equal to one unit

Eg: A 45 minutes procedure (From start to finish) it is 3 units of anesthesia time. Do not round up or down the total time.  (Total procedure time divided by 15)

Eg: For a 63-minute procedure, it is 4.2 time units 

       For a 79 minute procedure, it is 5.3 time units

Note: For certain insurance there may be round up or round down concepts applicable, anything below 7.5 minutes round down and above 8 min round up.


Note: For certain insurance there may be round up or round down concepts applicable, anything below 7.5 minutes round down and above 8 min round up. 

For Eg: 39 min should be considered as 3 units (15+15+9). And 37 min should be considered as 2 units (15+15+7).

Discontinuous Time:

There may be some interruptions in anesthesia care during a procedure; if the provider is no longer personally attending the patient should be recorded correctly about the interrupted timings.

Eg: The anesthesiologist begins care at 9.00, care interrupted at 9.25 (25 minutes) and resumes care at 9.30 ending care at 9.55 (25 minutes), there would be 50 minutes of anesthesia time. This would be 3.3 Time units.

Conversion Factor:

CMS releases annually and is specific to the locality where the anesthesia service is rendered
The anesthesia conversion factors: http://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Anesthesia Modifiers:

For Anesthesiologist

AA: Anesthesia services performed personally by anesthesiologist (or) an anesthetist assists a physician in the care of a single patient.

Modifier AA informs the insurance company that the anesthesiologist provided care to the patient alone, and not alongside a certified registered nurse anesthetist (CRNA).

QY: Medical direction of one Qualified Non-physician

Modifier QY tells the insurance company that the anesthesiologist was directing at least one CRNA.

QK: Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.

Modifier QK tells the insurance company to make adjustments for the anesthesiologist medically directing more than one case or procedure at the same time he or she is directing the CRNA on the reported case.

AD: Medical supervision by a physician: more than four concurrent anesthesia procedures.

Modifier AD describes a situation similar to that described by modifier QK, but with more involvement and a greater patient load.

For Non-physician Anesthetist

QX: Qualified Non-physician Anesthetist service: with medical direction by a physician.

          In this case, the CRNA is working under an anesthesiologist.

QZ: Qualified Non-physician Anesthetist service: without medical direction by a physician

         In this case, the CRNA is working without the direction of an anesthesiologist.

For MAC (Monitored Anesthesia Care)

QS: MAC (Can billed by Qualified Non-physician Anesthetist / Anesthesia Assistant / physician)

You must alert the insurance company when monitored anesthesia care(MAC), rather than general anesthesia, is performed. MAC is included in the payment for the procedure.

G8: MAC for deep complex or complicated / markedly invasive surgical procedure.

In this scenario, MAC is given when general anesthesia was most likely used for a procedure. For example, an 86-year-old patient undergoing hip surgery may have a better chance of survival if given MAC anesthesia rather than general anesthesia.

G9: MAC for patient who have severe cardiopulmonary conditions

Always add this modifier for patients receiving MAC who have cardiorespiratory deficits such as chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), or emphysema. You may also use the modifier for lung cancer patients who are terminally ill, or in end stages of the disease.

Physical Status Modifiers:

Physical status modifiers are used for reporting the overall physical health of a patient at the time of a procedure.

Billing Guidelines: Except Medicare all other insurance allow physical status modifiers to receive additional total units of anaesthesia service reported for patients.

Qualifying Circumstances:

Many anaesthesia services are provided under complicated circumstances, Depending on the risk factors there are few Qualifying circumstances add on codes are coded along with anaesthesia procedures in order to get higher payment.

+99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) is 1 unit of anesthesia.

(Some exceptions are 00326, 00561, 00834, 00836 procedures performed on infants younger than 1 year of age at the time of surgery).

+99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) is 5 unit of anesthesia.

Example: The patient undergoes removal of subdural hematoma.The physician feels it is necessary to put the patient in a complete,deliberate state of hypothermia to decrease blood flow to the regionof the brain. This is an effective way to decrease the oxygen-level requirements during surgery and decrease the incidence of postoperative neurological injury after neurosurgery.

+99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) is 5 unit of anesthesia.

Example: The patient undergoes clipping of an aneurysm. The physician deems it necessary, due to potential blood loss, for the patient to be placed into hypotension to decrease blood flow to the areas
in which the work will be performed. This is also used in head,face, upper thorax, or hip replacement surgeries, as the need for a blood transfusion is greatly reduced.

+99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) is 2 unit of anesthesia.

A 33-year-old male is playing with his son, throwing a football in the living room. The patient falls through a plate glass door, causing a severe laceration of the brachial artery in his left arm. Upon arrival to the ED, the patient undergoes emergency surgery to repair the artery to prevent loss of limb.


3. Append






Unusual position and Field avoidance:

Procedures of the head, neck, or shoulder girdle requiring field avoidance.

Procedures performed in a position other than supine or lithotomy.

For either of the above circumstances, a minimum base unit of 5 should be used.

Field avoidance indicates that the anaesthesia provider does not have access to the patient’s airway during surgery. This may be due to the nature of the case (i.e., face or shoulder surgery) or because the surgeon has the patient in a different position. Both field avoidance and unusual positioning make the case a higher risk for the patient and the anaesthesia provider. For special positioning, surgeries performed in either the supine (patient is lying on their back) or lithotomy (patient is on their back with the hips and knees flexed and the thighs apart) are also excluded.