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CHAPTER 12

ANESTHESIA

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Anesthesiologist

Doctor of medicine specialized in anesthesia

Usually independent practices (not hospital employees)

e.g., Anesthesia Associates, Inc. or Pain Clinic, Ltd.

Services reported separately

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The anesthesiologist is a physician whose medical specialty is anesthesia. These specialists are often members of outside practices who report their services separately.

Why would the anesthesiologist’s services be reported separately? (Because it is a separate physician who specializes in this type of medicine)

Uses of Anesthesia

Relieve pain

Manage

Unconscious patients

Life functions

Resuscitation

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Use of anesthesia creates a state of analgesia (the absence of pain) that allows the patient to have surgery or another procedure performed without experiencing pain.

The anesthesiologist’s job is to administer medications that will induce general, regional, local, or conscious sedation in the patient while managing the life functions of the unconscious patient and directing respiratory or cardiac resuscitation efforts.

If a patient suffers cardiac arrest while on the operating table, why is the anesthesiologist the one to manage the problems associated with resuscitation? (He or she is responsible for management of the patient while under anesthesia.)

Methods of Anesthesia (1 of 3)

Figure 12.1A

Endotracheal: Through mouth

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What is anesthesia? (Administration of a drug to obtain loss of sensation.)

Ask students to identify different types of anesthesia. (General, regional, local, or monitored anesthesia care [MAC])

When will endotracheal anesthesia be administered? (When general anesthesia is needed; major procedure)

This figure shows one method of delivering general anesthesia. Endotracheal anesthesia is accomplished by inserting a tube into the nose or mouth and delivering a gaseous drug through the tube.

Methods of Anesthesia (2 of 3)

Figure 12.2

Local: Application to area (injection or topical)

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With local anesthesia, an anesthetic agent such as lidocaine is directly applied to the area involved as a topical anesthesia or is administered by local infiltration through a subcutaneous injection, as shown in Fig. 12.2.

What types of procedures would use local anesthesia? (Relatively minor procedures such as tooth extraction or suturing a wound would be candidates.)

What is a key difference between local and general anesthesia? (There is no loss of consciousness with local anesthesia as there is when a general is administered.)

Methods of Anesthesia (3 of 3)

Epidural: Into epidural space

Regional: Field or nerve

Includes spinal and epidural

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When is an epidural anesthesia used? (To numb certain parts of the body)

When would you expect epidural anesthesia to be used? (With operations on the leg or pelvic region, and it is commonly used during childbirth.)

Regional anesthesia involves blocking the nerve supply to a part of the body in order to eliminate pain. It is produced by a field block (forming a wall of anesthesia around the site by means of local injections) or nerve block (injection of the nerves close to the site).

Patient-Controlled Analgesia (PCA)

Patient administers drug

Often used to control acute postop or chronic pain

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When the patient presses a button, a predetermined amount of a prescribed drug is released. The patient controls the amount and frequency of the drug’s administration.

What are the advantages of patient-controlled analgesia (PCA)? (The patient is in control of his or her own pain management. In addition, because medication is delivered only when the patient deems it necessary, and not according to a fixed schedule, the overall amount required to treat the condition may be less, despite the patient’s report of higher levels of comfort.)

Moderate (Conscious) Sedation

Patient controls his/her airway and can respond to verbal commands

General renders the patient unconscious

Decreased level of consciousness

Report with 99151-99157 (Medicine)

Codes divided on:

Age > or < 5

Time

Provided by physician performing service (99151-99153) or other physician (99155-99157)

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Conscious sedation provides a decreased level of consciousness but does not actually put the patient to sleep. The patient can breathe without assistance and can respond to stimulation and verbal commands. Nonetheless, a trained observer must be present to assist in monitoring the patient.

Codes 99151-99153 are used when the same physician performing the procedure performs the conscious sedation.

Codes 99155-99157 are used when the conscious sedation is performed by a different physician.

Anesthesia Section Format

Figure 12.4

Anatomic divisions

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How are codes organized in the anesthesia section of the CPT? (The first major subdivision is based on anatomical site. The second subdivision is based on the type of procedure performed. However, there is an exception to this. The last four subsections in Anesthesia—Radiologic Procedures [01916-01936], Burn Excisions or Debridement [01951-01953], Obstetrical [01958-01969], and Other Procedures [01990-01999]—are not organized by anatomical division.)

Anesthesia Formula

B + T + M

1. Base units

2. Time units

3. Modifying units

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The CPT codes for anesthesia services include preoperative, intraoperative, and postoperative care. Anesthesia services are billed according to a standard formula for payment that is generally accepted throughout the United States. The formula is (Base Units + Time Units + Modifying Units) x Conversion Factor.

How does this formula reflect the services provided by the anesthesiologist? (This formula reflects the basic service provided, the amount of time spent, and any special circumstances that alter the standard treatment expected for the service delivered. These are the key elements that will determine the value of the anesthesiologist’s presence during the procedure.)

B is for Base Unit

Published in RVG (Relative Value Guide®) by ASA

National unit values for anesthesia services

Based on complexity

Base Unit Value (BUV)

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What does ASA stand for? (The American Society of Anesthesiology)

The Relative Value Guide® (RVG) contains codes for anesthesia services, most of which are included in the Anesthesia section of the CPT. The purpose of the RVG is to compare the complexity of various anesthesia services so that the relative value of each service, when compared with all services, may be assigned. The Basic Unit Value for a service is this RVG value.

How will the basic unit be assigned when multiple surgical procedures are performed together? (It will be based on the value assigned to the most complex procedure performed. In this case, the services delivered will be matched to the more complex surgical procedure.)

Relative Value Guide® (RVG) (1 of 3)

Lists all CPT anesthesia codes

Italicized comments added to ASA’s RVG

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Codes not currently in the CPT will ordinarily be added with the next revision.

Why will the RVG include codes not yet in the CPT? (As advances are made in medical practice, it is necessary to account for new procedures that come into use. Because the RVG is updated to reflect these, it will likely come out of alignment with the CPT from time to time. This is preferable to delaying notations for these services in that doing so would render the formula obsolete in some instances because it would lack needed information.)

Figure 12.8

Base Unit Values assigned to each code

Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Relative Value Guide® (RVG) (2 of 3)

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Fig. 12.8 shows a sample entry from the CPT Anesthesia section. Note the basic unit value notation on the right side of the entry.

What does the + TM notation refer to? (The other two components of the formula, time and modifying unit)

Anesthesia services paid on set amount per unit (conversion factor)

Example: Medicare unit value, North Carolina in 2020 was $21.63

Relative Value Guide® (RVG) (3 of 3)

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In the example on this slide, what is the significance of the notation North Carolina in 2020? (Each third-party payer issues a list of conversion factors. The lists vary with geographic location because the cost of practicing medicine varies from one region to another. See Fig. 12.13 on slide 23 for an example of a third-party payer’s anesthesia conversion factors.)

T is for Time (1 of 2)

Patient record indicates time, e.g., 15, 30, 60 minutes

Often, 15 minutes = 1 unit

60 minutes = 4 units

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Time is measured from the beginning of the preoperative period, when time is spent preparing the patient to receive anesthesia, through the time when the patient ceases to be under the care of the anesthesiologist during the postoperative period. This time is recorded in the patient record. The amount of time represented by a unit varies for different carriers but will typically be 15 or 30 minutes.

What effect will the carrier’s standard for the number of minutes in a unit have on reimbursement? (None. Carriers independently determine the amount of time that is considered a unit.)

T is for Time (2 of 2)

Begins: Anesthesiologist begins to manage patient in the operating room—preop

Continues throughout procedure—intraop

Ends: Patient no longer under care of anesthesiologist—postop

Example: Anesthesia time started at 9 AM and the patient discharged to PACU at 1:30 PM would be 270 minutes.

PACU = Post-Anesthesia Care Unit

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Why does time include periods when the patient is not under anesthesia? (Time reflects the anesthesiologist’s services, including time spent before [preparation], during, and after surgery.)

M is for Modifying Unit

Physical condition indicated by physical status modifier

P1 – P6, in Anesthesia Guidelines

Risk Factor

Not reported for Medicare

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Modifying units reflect circumstances or conditions that change the environment in which the anesthesia service is provided. Physical status modifiers are an indicator of the level of complexity of the services required to treat that patient.

Why are physical status modifiers necessary? (Patients who have chronic illnesses or other conditions that affect their general health over and above the impact of the condition that led to surgery will require additional care and oversight by the anesthesiologist during surgery. Modifiers reflect the added service requirements of these patients and ensure that compensation does as well.)

Physical Status Modifiers, P1 through P6

(…Cont’d)

P1 Normal, healthy

P2 Mild systemic disease

P3 Severe systemic disease

P4 Severe systemic disease and in constant threat to life

P5 Not expected to survive without operation

P6 Brain dead

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The physical status modifier begins with the letter P and is followed by a single digit.

Why are the relative values for P1 and P2 both zero? (P1 is used for a normal, healthy patient. Services for this patient are already reflected in the B + T of the reimbursement formula—it is based on the treatment of this type of patient. Although the patient classed as P2 has some systemic disease, it is not significant enough to have an effect on the nature of the treatment the patient will receive from the anesthesiologist. For this reason, it is also coded as 0.)

Physical Status Modifiers

Payment differential based on some physical status ratings

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How do the relative values of physical status modifiers P4, P5, and P6 differ? (P4 is assigned a value of 2, P5 a value of 3, and P6 a value of 0. Recall that a patient with a P3 status has severe systemic disease, but it is not life threatening. It is assigned a value of 1. P3, P4, and P5 are steps on a scale that describes the impact of patient condition on anesthesia services. P6 is assigned a value of 0 because the patient is clinically dead and cannot benefit from extraordinary services.)

Another Modifying Unit

Qualifying Circumstances, 99100–99140

In Anesthesia Guidelines

Also in Medicine section

Not reported for Medicare

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Qualifying services codes are CPT codes that begin with the digits 99. These are treated as add-on codes and must accompany the anesthesia procedure code. They may not stand alone.

Qualifying circumstances include the following:

(99100) Anesthesia for patient of extreme age, younger than one year and over seventy—Relative Value 1

(99116) Anesthesia complicated by utilization of total body hypothermia—Relative Value 5

(99135) Anesthesia complicated by utilization of controlled hypotension—Relative Value 5

(99140) Anesthesia complicated by emergency conditions—Relative Value 2

Qualifying Circumstances Codes and Relative Value

Figure 12.10

Listed in addition to primary anesthesia code

Excerpted from 2020 Relative Value Guide®, © 2019 of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973, or online at www.asahq.org.

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Which qualifying circumstance has the greatest impact on the relative value of the modifier? (Use of hypothermia or hypotension will have the greatest impact. In both cases, the patient’s heart rate and respiration are slowed markedly, as they would be if these conditions were achieved accidentally. The threat to the patient is greater in these cases, the level of services required is greater, and the relative value must therefore be greater.)

Summation of Formula

Base units (from RVG) based on CPT codes

Time units (often, 15 min. = unit)

Modifiers [Qualifying Circumstances (99100–99140) and/or Physical Status (P1-P6)]

B+T+M = Total Units × $ (CF) = payment

CF = Conversion factor

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Case: An 84-year-old female with severe hypertension had a 4-cm malignant lesion removed from her right knee. The total time of anesthesia service was 60 minutes. The medical record indicates that the patient’s physical status was P3 for severe systemic disease.

How many time units were delivered if a time unit is 15 minutes? What modifiers apply, and what is their total value? (The patient was treated for 60 minutes, or 4 time units. The patient is older than 70 years of age, warranting use of qualifying services code 99100, which has a value of 1. The patient has severe systemic disease, which is a physical status of P3, which has a value of 1. The total modifier value is 2.)

Conversion Factors

Figure 12.13

2020 CMS Anesthesia Conversion Factors

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Why are conversion factors important? (So a physician would know prior to the procedure performed what the reimbursement amount will be)

Anesthesia for Multiple Surgical Procedures

Once anesthetized, length of time not number of procedures

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How are anesthesiology services coded when multiple procedures are performed? Why? (The code will be based on the most complex procedure performed because the services delivered will be matched to the most complex surgical procedure. Codes for each of the procedures delivered will not be used because they occur within the span of a single anesthetic delivery. The inclusion of multiple procedures will, however, increase the total time of the procedure.)

Multiple Service

Example: two procedures during same session

One, 10 base unit value; the other, 5 base unit value

Report only 10 base unit value

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This slide illustrates how basic units would be calculated for a case in which two procedures of varying complexity are delivered.

What other factors will influence the total units delivered for this procedure? (The amount of time spent delivering the service, which will be greater for the two procedures than for either carried out on its own)

HCPCS Modifiers

Added to anesthesia code

-AA = Anesthesia by Anesthesiologist

-AD Physician, medical supervision, 4+ concurrent procedures

-G8 MAC (monitored anesthesia care), complex procedures

-G9 MAC, patient history of severe cardiopulmonary condition

-QK Qualified individual, medical direction of 2, 3, 4 concurrent cases

-QS MAC

-QX CRNA, directed by physician

-QY MAC, anesthesiologist directing one CRNA

-QZ CRNA, without direction

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How are the HCPCS modifiers used in the coding of anesthesia services? (These modifiers define the types of providers involved in the care of the patient. They provide additional information about the services performed that will be important to third-party payers who are processing claims for reimbursement.)

Conclusion CHAPTER 12

ANESTHESIA

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