Fee Schedule - Anesthesia 2015 01/01/2015
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CPT® only copyright © 2014 American Medical Association. All rights reserved.
Copyright Notice The five character codes included in the North Dakota Fee Schedule are obtained from the Current Procedural Terminology (CPT), copyright 2014 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of North Dakota Fee Schedules is with WSI and no endorsement by the AMA is intender or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in North Dakota Fee Schedule. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside of North Dakota Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply. CPT is a registered trademark of the American Medical Association. ADA codes are copyright © 2014 American Dental Association. All Rights Reserved. Reproduced and distributed under ADA License #2002460.
CPT® only copyright © 2014 American Medical Association. All rights reserved.
Table of Contents Anesthesia Payment Methodology .................................................................... 4 Payment Parameters ......................................................................................... 5 Code 00100-00952 ............................................................................................ 6 Code 01112- 01999 ......................................................................................... 10
CPT® only copyright © 2014 American Medical Association. All rights reserved.
Anesthesia Payment Methodology The medical fee schedule uses the procedure codes and descriptions of the American Medical Association’s physicians Current Procedural Terminology (CPT®). Fees are calculated using the Resource Based Relative Values (RBRVS) RVU weights established by the Centers for Medicare & Medicaid (CMS) The medical and hospital fee schedules contain the entire list of CPT identifying codes. The listing of CPT codes in the fee schedules is not a guarantee of payment. WSI shall use the following conversion factor table to determine the maximum allowable fee by multiplying the conversion factor by the relative value unit established in the RBRVS. The Anesthesia Fee Schedule Conversion Factor will be updated each year by the same percentage as the WSI Medical Fee Schedule. Conversion Factor Table Specialty Groups Anesthesia (Time Units & Risk Units)
Conversion Factor 56.63
WSI will pay for professional anesthesia services on a per case basis. WSI shall use the following formula to determine the maximum allowable reimbursement for each anesthesia case: Basic Value + Units
Time Units +
Physical Status Modifier
X
Conversion Factor =
Maximum Allowable Reimbursement
One time unit equals 15 minutes, regardless of the length of the procedure. Under the per case payment methodology:
When an MDA or a CRNA personally performs a case, the full case payment will be made to that provider When a CRNA performs a case under the Medical Direction of an MDA: o The CRNA is paid for 50% of the per case amount o The MDA is paid for 50% of the per case amount
CPT® only copyright © 2014 American Medical Association. All rights reserved.
Anesthesia Fee Schedule Payment Parameters WSI requires that the following anesthesia payment modifiers be used as appropriate: AA MDA personally performs a case AD MDA medically supervising more than 4 concurrent anesthesia procedures QY MDA medically directing one CRNA QK MDA medically directing 2 – 4 CRNAs QZ CRNA performs case without medical direction QX CRNA performs case with medical direction WSI will allow payment for the following patient status modifiers: P3 A patient with severe systemic disease – one additional unit is paid P4 A patient with severe systemic disease that is a constant threat to life – two additional units are paid P5 A moribund patient who is not expected to survive without the operation – three additional units are paid For medically directed cases, both the CRNA and MDA may use these modifiers. There will be no separate payment for patient status modifiers P1, P2 & P6. WSI will allow payment for the following add on anesthesia service CPT codes: 99100 Anesthesia for patients of extreme age, under 1 year and over 70 – one additional unit is paid 99116 Anesthesia complicated by utilization of total body hypothermia – 5 additional units are paid 99135 Anesthesia complicated by utilization of controlled hypothermia – 5 additional units are paid 99140 Anesthesia complicated by emergency conditions – two additional units are paid For medically directed cases, both the CRNA and MDA may use these add on codes. An MDA filing a claim for medical direction of a CRNA must meet all of the seven Medical Direction criteria as required by CMS. The MDA must: Perform a pre-anesthetic examination and evaluation; Prescribe the anesthesia plan; Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence; Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist; Monitor the course of anesthesia administration at frequent intervals; Remain physically present and available for immediate diagnosis and treatment of emergencies; and CPT® only copyright © 2014 American Medical Association. All rights reserved.
Provide indicated post-anesthesia care
All claims for anesthesia services must be billed on a 1500 claim form. The actual number of anesthesia minutes will be reported as the number of units. The payment modifiers (AA, QY, QK, QZ & QX) must be in the first modifier position on the claim. Claims submitted without a payment modifier will be returned to the provider. Patient status modifiers must be in the second modifier position on the claim. In unusual circumstances when it is medically necessary for both the CRNA and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report the service using the “AA” modifier and the CRNA would use “QZ”. When both a CRNA and an MDA claim using these modifiers are received for a single anesthesia case, WSI will request documentation to support payment of the full fee for both providers. Non Anesthesia services, such as insertion of catheters, placement of central venous and arterial lines, intubations, pain management services, etc. are paid under the WSI Medical Fee Schedule. They are billed as procedures with a unit of one and no anesthesia payment or patient status modifiers.
CPT® only copyright © 2014 American Medical Association. All rights reserved.
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
Code 00100-00952 00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00211 00212 00214 00215 00216 00218 00220 00222 00300 00320 00322 00326 00350 00352 00400 00402 00404 00406 00410 00450
5 6 5 4 5 4 4 5 4 6 6 4 4 5 7 4 5 6 6 7 5 7 11 10 5 9 9 15 13 10 6 5 6 3 7 10 5 3 5 5 13 4 5 CPT® only copyright © 2013 American Medical Association. All rights reserved.
6
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
00454 00470 00472 00474 00500 00520 00522 00524 00528 00529 00530 00532 00534 00537 00539 00540 00542 00541 00546 00548 00550 00560 00561 00562 00563 00566 00567 00580 00600 00604 00620 00625 00626 00630 00632 00635 00640 00670 00700 00702 00730 00740 00750 00752 00754
3 6 10 13 15 6 4 4 8 11 4 4 7 7 18 12 15 15 15 17 10 15 25 20 25 25 18 20 10 13 10 13 15 8 7 4 3 13 4 4 5 5 4 6 7 CPT® only copyright © 2013 American Medical Association. All rights reserved.
7
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
00756 00770 00790 00792 00794 00796 00797 00800 00802 00810 00820 00830 00832 00834 00836 00840 00842 00844 00846 00848 00851 00860 00862 00864 00865 00866 00868 00870 00872 00873 00880 00882 00902 00904 00906 00908 00910 00912 00914 00916 00918 00920 00921 00922 00924
7 15 7 13 8 30 11 4 5 5 5 4 6 5 6 6 4 7 8 8 6 6 7 8 7 10 10 5 7 5 15 10 5 7 4 6 3 5 5 5 5 3 3 6 4 CPT® only copyright © 2013 American Medical Association. All rights reserved.
8
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
00926 00928 00930 00932 00934 00936 00938 00940 00942 00944 00948 00950 00952
4 6 4 4 6 8 4 3 4 6 4 5 4
CPT® only copyright © 2013 American Medical Association. All rights reserved.
9
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
Code 01112- 01999 01112 01120 01130 01140 01150 01160 01170 01173 01180 01190 01200 01202 01210 01212 01214 01215 01220 01230 01232 01234 01250 01260 01270 01272 01274 01320 01340 01360 01380 01382 01390 01392 01400 01402 01404 01420 01430 01432 01440 01442 01444
5 6 3 15 10 4 8 12 3 4 4 4 6 10 8 10 4 6 5 8 4 3 8 4 6 4 4 5 3 3 3 4 4 7 5 3 3 6 8 8 8 CPT® only copyright © 2013 American Medical Association. All rights reserved.
10
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
01462 01464 01470 01472 01474 01480 01482 01484 01486 01490 01500 01502 01520 01522 01610 01620 01622 01630 01634 01636 01638 01650 01652 01654 01656 01670 01680 01682 01710 01712 01714 01716 01730 01732 01740 01742 01744 01756 01758 01760 01770 01772 01780 01782 01810
3 3 3 5 5 3 4 4 7 3 8 6 3 5 5 4 4 5 9 15 10 6 10 8 10 4 3 4 3 5 5 5 3 3 4 5 5 6 5 7 6 6 3 4 3 CPT® only copyright © 2013 American Medical Association. All rights reserved.
11
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE ANESTHESIA
CPT CODE
TOTAL RVU
01820 01829 01830 01832 01840 01842 01844 01850 01852 01860 01916 01920 01922 01924 01925 01926 01930 01931 01932 01933 01935 01936 01951 01952 01953 01958 01960 01961 01962 01963 01964 01965 01966 01967 01968 01969 01990 01991 01992 01995 01996 01999
3 3 3 6 6 6 6 3 4 3 5 7 7 5 7 8 5 7 6 7 5 5 3 5 1 5 5 7 8 8 4 4 4 5 2 5 7 3 5 5 3 0
CPT® only copyright © 2013 American Medical Association. All rights reserved.
12
