Anesthesia and Fee Calculation

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
January 29th, 2018

Fees for anesthesia services are not calculated or reported the same as for other types of procedures, we have identified some of the most common rules used for reporting anesthesia in this article. Please refer to your MAC Carrier, third party payer and the AMA guidelines for more detailed information. 

Conscious Sedation

If conscious sedation is being provided by the same physician doing the procedure refer to codes 99151-99153. 

If there is another physician administering the moderate conscious sedation with a separate physician performing the procedure in a facility setting, the other physician may report codes 99155-99157 NOTE: These not reported for services in a physician's office or freestanding imaging center, for services in the office, home, hospital or consult see the Evaluation Management section 99201-99499. 

Multiple Procedures

When multiple procedures are performed at the same time under the same anesthesia, code the most complex procedure and add the total time for all procedures during the same encounter. 

Status Code

If you are not getting the desired fees expected, be sure to check the status code and payment indicators (Located under Additional Code Information - PURPLE tab). For example, a CPT code with a "J" status code is indicating the following;

There are four elements to consider when calculating anesthesia fees. Medicare accepts base units and time units; however, depending on the third-party payer, they may or may not accept physical status units and/or qualifying circumstances units.

1. Base Unit (of the CPT code)
2. Time (in 15-minute increments)
3. Physical Status (P1, P2, P3, P4, P5, P6)
4. Qualifying Circumstances (four CPT add-on code options: 99100, 99116, 99135, 99140)

FindACodes fee calculator for Anesthesia units can be found on the code information page on the code you need pricing for. The calculator uses Medicare conversion factors based on geographical location and calculates fees from the base unit and amount of time reported, which may or may not include physical status modifiers and qualifying circumstances.

Example: 

Physical Status Modifiers

Physical Status Modifiers is a classification system under the classifications and guidelines used for more than 60 years by the American Society of Anesthesiologists to communicate a patients' pre-anesthesia medical co-morbidities. 

For example, 

• A Normal Healthy Patient is a P1
• A patient with mild systemic disease is a P2
• A patient with a severe systemic disease is a P3
• A patient with severe systemic disease that is a constant threat to life is a P4

If the private payer accepts Physical Status (PS) and/or Qualifying Circumstances (QC) as units, these may also be included as part of the fee calculation. Below, the general value of units is shown with each PS Modifier or QC add-on code. Assigning these modifiers and CPT codes may affect payment, for example, according to Moda Health and Unitedhealthcare, they follow the standard Anesthesia Formula below

• P3 modifier is equal to 15 minutes or 1 base unit.
• P4 modifier is equal to 30 minutes or 2 base units
• P5 is equal to 45 Minutes or 3 Base units 

NOTE: Medicare does not recognize Physical status modifiers, Always check the payer policies to see if these rules apply and if the unit values are different:

American Society of Anesthesiologists ranking of patient physical status, which can also be found at the ASA web site www.asahq.org/clinical/physicalstatus.htm.

REF: "Using Physical Status Modifiers with Anesthesia Codes"

Qualifying Circumstances for Anesthesia

Other Modifiers

CMS and other payers require the use of the following modifiers, these are used by qualified non-physician anesthetists when billing for anesthesia services:

These MUST be billed in the first position:

• AA – Anesthesia services performed personally by an anesthesiologist.
• QK – Medical direction by a physician of two, three, or four concurrent anesthesia procedures.
• AD – Medically supervised by a physician, more than four concurrent anesthesia procedures.
• QS – Monitored anesthesia care services
• QY – Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an anesthesiologist.
• QX – CRNA/AA (Anesthesiologist's Assistant) service with medical direction by a physician.
• QZ – CRNA service without medical direction by a physician.

REF: Anesthesia Documentation Modifiers CMS Pub-100 

NOTE: The QS modifier can be used by a physician or a qualified non-physician anesthetist and is for informational purposes. Providers must report actual anesthesia time and one of the payment modifiers on the claim.

For more information on CMS billing with modifiers and Anesthesia Billing see the Pub 100-04 Medicare Claims Processing Manual

References:

• UnitedHealthcare Oxford - Anesthesia Policy Eff Date 01/01/2020
• American Society of Anesthologists
• Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners