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Anesthesia and Pain Management

October 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Anesthesia|Pain Management   Modifiers   Office of Inspector General (OIG)  
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Anesthesia and Pain management is under close watch from the OIG according to a report from Anesthesia Business consultants, they stated, "The Health and Human Services Office of Inspector General (HHS OIG) reports in its most recent Semi-annual Report to Congress that in FY 2017 it brought criminal actions against 881 individuals or organizations engaging in crimes against HHS programs and their beneficiaries, and an additional 826 civil actions, including false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements and administrative recoveries related to provider self-disclosure matters. OIG excluded 3,244 individuals and entities from participation in federal healthcare programs.”

This is not to mention the public health concern for chronic pain management and the growth of opioids prescribed. The CDC has developed and published guidelines for prescribing opioids for chronic pain to improve the way opioids are prescribed and hopes to reduce the number of patients who misuse or overdose with these drugs.  

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Anesthesia Billing

Anesthesia is reimbursed for the most part on the amount of time spent providing patient care. Therefore, it is important to correctly record the Start-Stop Time in the medical record. When billing for anesthesia services, there is a formula used to determine the allowed time.  Generally, the Anesthesia formula is as follows (Time Unit + Base Unit) X Conversion Factor = Allowed.

Prior to 2017 moderate sedation was indicated by a red bulls-eye on a CPT code that included moderate sedation. This was removed by the AMA in 2017 that affected over 700 codes. When using these codes moderate sedation needs to be coded separately.

Payment can also be made for anesthesia services with multiple procedures and is based on the procedure with the highest base unit value.

Modifiers for anesthesia billing identify specific situations and are required to report the type of provider that furnished the service.  For example, an anesthesiologist can medically direct several cases at one time done by a qualified Non-physician anesthetist.  If an anesthesiologist is medically supervising more than four concurrent anesthesia procedures the AD modifier is reported. The AA Modifier was the focus of the OIG Anesthesia investigations in 2015.

A few examples of modifiers are:

For Medicare, Claims processing see the CMS Manual Pub-100-04

Click Here for a great resource for an anesthesia guide from CMS Palmetto GBA.

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