Benefits fr Anesthesia Services fr the CSHCN Services Prgram t Change Effective fr dates f service n r after July 1, 2008, benefit criteria fr anesthesia will change fr the Children with Special Health Care Needs (CSHCN) Services Prgram. Click n the title t view the details. Anesthesia is a benefit f the CSHCN Services Prgram and is payable t anesthesilgists and certified registered nurse anesthetists (CRNAs). Anesthesia must be administered by an anesthesia practitiner. An anesthesia practitiner is defined as: An anesthesilgist. A CRNA. A qualified prfessinal as identified by the Texas Medical Bard (TMB) perfrming delegated services. Authrizatin is nt required fr anesthesia. Specific surgical prcedures, hwever, may require prir authrizatin. Anesthesia may be reimbursed if prir authrizatin fr the surgical prcedure was nt btained, but services prvided by the facility, surgen, and assistant surgen will be denied. Fr time-based anesthesia prcedure cdes, anesthesia practitiners must dcument interruptins in anesthesia time in the client s medical recrd. Anesthesia time begins when the anesthesia practitiner begins t prepare the client fr the inductin f anesthesia in the perating rm r the equivalent area and ends when the anesthesia practitiner is n lnger in persnal attendance (e.g., when the client may be safely placed under pstperative supervisin). The dcumented time must be the same in the recrds r claims f the anesthesilgist and ther anesthesia practitiners wh were medically directed by the anesthesilgist. One time unit is equal t 15 minutes f anesthesia. Prviders must submit the ttal anesthesia time in minutes n the claim. The claims administratr will cnvert ttal minutes t time units. T be reimbursed, prviders f anesthesia services must include the fllwing n submitted claims: apprpriate anesthesia prcedure cdes, the crrect mdifier(s), the name f the anesthesilgist r CRNA administering the anesthesia, and the exact amunt f face-t-face time with the client. Prcedure cdes 1-99100, 1-99116, 1-99135, and 1-99140 are qualifying circumstances that impact the character f the anesthesia services prvided. These prcedures are nt payable alne but are payable in additin t the anesthesia service. Dcumentatin supprting the medical necessity fr use f the prcedure cdes may be subject t retrspective review. If anesthesia services are perfrmed fr tw surgical prcedures at separate times during the same date f service, bth may be reimbursed based n the dcumentatin submitted with the claim.
Medical Directin Persnal medical directin by an anesthesilgist f an anesthesia practitiner is a benefit f the CSHCN Services Prgram if the fllwing criteria are met: N mre than fur anesthesia prcedures are being perfrmed cncurrently. Exceptin: Anesthesilgists may medically direct mre than fur anesthesia services r simultaneusly supervise mre than a cmbinatin f fur CRNAs r ther qualified prfessinals as defined by the TMB under emergency circumstances nly. The anesthesilgist is physically present in the perating suite. Medical directin is a cvered service nly if all f the fllwing criteria are met: The anesthesilgist perfrms a pre-anesthetic examinatin and evaluatin. The anesthesilgist prescribes the anesthesia plan. The anesthesilgist persnally participates in the critical prtins f the anesthesia plan, including inductin and emergence. The anesthesilgist must ensure that a qualified prfessinal can perfrm the prcedures in the anesthesia plan that the anesthesilgist des nt perfrm persnally. The anesthesilgist mnitrs the curse f anesthesia administratin at frequent intervals. The anesthesilgist remains physically present and available fr immediate diagnsis and treatment f emergencies. The anesthesilgist prvides pstanesthesia care. The anesthesilgist des nt perfrm any ther services (except as nted belw) during the same time perid. The anesthesilgist directing the administratin f n mre than fur anesthesia prcedures may prvide the fllwing withut affecting the eligibility f the medical directin services: Address an emergency f shrt duratin in the immediate area. Administer an epidural r caudal anesthetic t ease labr pain fr a client wh is nt enrlled in the CSHCN Services Prgram. Prvide peridic, rather than cntinuus, mnitring f an bstetrical client wh is nt enrlled in the CSHCN Services Prgram. Receive clients entering the perating suite fr the next surgery. Check r discharge clients in the recvery rm. Handle scheduling matters.
As nted abve, an anesthesilgist may cncurrently medically direct up t fur anesthesia prcedures. Cncurrency is defined as the maximum number f prcedures that the anesthesilgist is medically directing within the cntext f a single prcedure and whether thse ther prcedures verlap each ther. Cncurrency is nt dependent n each f the cases invlving a CSHCN Services Prgram client. Fr example, if three prcedures are medically directed but nly tw invlve CSHCN Services Prgram clients, the CSHCN Services Prgram claims shuld be billed as cncurrent medical directin f three prcedures. The fllwing infrmatin must be available t state agencies upn request and is subject t retrspective review: The name f each CRNA and ther qualified prfessinal cncurrently that is medically directed r supervised and a descriptin f the prcedure that was perfrmed must be dcumented and maintained n file. Signatures f the anesthesilgist, CRNAs, r ther qualified prfessinals invlved in administering anesthesia services must be dcumented in the client s medical recrd. Mnitred Anesthesia Care Mnitred anesthesia care may include any f the fllwing: Intraperative mnitring by an anesthesilgist r qualified prfessinal under the medical directin f an anesthesilgist. Mnitring f the client s vital physilgical signs in anticipatin f the need fr general anesthesia. Mnitring f the client s develpment f an adverse physilgical reactin t a surgical prcedure. Anesthesia Mdifiers Each anesthesia prcedure cde must be submitted with the apprpriate anesthesia mdifier(s) whether billing as the sle prvider r fr the medical directin f CRNAs r ther qualified prfessinals. When an anesthesia service is billed withut the apprpriate reimbursement mdifiers r is billed with mdifier cmbinatins ther than thse listed in this article, the claim will be denied. A prcedure billed with a mdifier indicating that the anesthesia was nt medically directed r medically supervised (mdifier AD, QK, QX, r QY) will be denied if a previus claim has been billed with a mdifier indicating the service was persnally perfrmed (mdifier AA r QZ) fr the same client, date f service, and prcedure cde. A prcedure billed with a mdifier indicating that the anesthesia was persnally perfrmed by an anesthesilgist (mdifier AA) will be denied if anther claim has been paid indicating the service was persnally perfrmed by, and reimbursed t, a CRNA (mdifier QZ) fr the same client, date f service, and prcedure cde. The ppsite is als true a CRNA-administered prcedure will be denied if a previus claim was paid t an anesthesilgist fr the same client, date f service, and prcedure cde. Denied claims may be appealed with supprting dcumentatin f any unusual circumstances.
State-Defined Mdifiers Mdifiers U1 (indicating ne anesthesia claim is expected) and U2 (indicating tw anesthesia claims are expected) are state-defined mdifiers that may be billed by an anesthesilgist r CRNA. Mdifier U3 is used t indicate that the anesthesia was perfrmed with dental services. Mdifier U1, indicating that nly ne claim will be submitted, cannt be billed by tw prviders fr the same prcedure, client, and date f service. Mdifier U2, indicating that tw claims will be submitted, can nly be billed by tw prviders fr the same prcedure, client, and date f service if ne f the prviders was medically directed by the ther. Denied claims may be appealed with supprting dcumentatin f any unusual circumstances. Anesthesia prviders must submit the U1 r U2 mdifier with an apprpriate pricing mdifier when billing fr anesthesia prcedure cdes. Anesthesilgist Services Mdifiers AA and U1 must bth be submitted when an anesthesilgist has persnally perfrmed the anesthesia service. Anesthesilgists may be reimbursed fr medical directin f anesthesia practitiners by using ne f the fllwing mdifier cmbinatins: Mdifier Cmbinatin Submitted by Anesthesilgist When is it used? Wh will submit claims? Anesthesilgist Prviding Medical Directin r Medical Supervisin t Nn-CRNA Qualified Prfessinals QY and U1 When medically directing Only the anesthesilgist ne prcedure prvided by a nn-crna qualified prfessinal QK and U1 When medically directing tw, three, r fur cncurrent prcedures prvided by nn-crna qualified prfessinals Only the anesthesilgist AD and U1 (Emergency circumstances nly) When medically supervising five r mre cncurrent prcedures prvided by nn-crna qualified prfessinals. Used in emergency circumstances nly and limited t 6 units (90 minutes) per case fr each ccurrence requiring five r mre cncurrent prcedures. Only the anesthesilgist Anesthesilgist Prviding Medical Directin r Medical Supervisin f CRNAs
QY and U2 QK and U2 AD and U2 (Emergency circumstances nly) CRNA Services When medically directing ne prcedure prvided by a CRNA When medically directing tw, three, r fur cncurrent prcedures invlving CRNA(s) When medically supervising five r mre cncurrent prcedures invlving CRNA(s). Used in emergency circumstances nly and limited t 6 units (90 minutes) per case fr each ccurrence requiring five r mre cncurrent prcedures. Bth the anesthesilgist and CRNA Bth the anesthesilgist and CRNA Bth the anesthesilgist and CRNA Mdifiers QZ and U1 must be submitted when a CRNA has persnally perfrmed the anesthesia services, is nt medically directed by the anesthesilgist, and is directed by the surgen. Mdifiers QX and U2 must be submitted by a CRNA wh prvided services under the medical directin f an anesthesilgist. Mnitred Anesthesia Care Anesthesilgists r CRNAs may use mdifier QS t reprt mnitred anesthesia care. The QS mdifier is an infrmatinal mdifier, and must be billed with any cmbinatin f pricing mdifiers fr reimbursement. Reimbursement The anesthesilgist s reimbursement fr medical directin f nn-crna qualified prfessinals is 100 percent f the maximum allwable fee. When an anesthesilgist medically directs nly ne CRNA and bth prfessinals submit claims, then 100 percent f the maximum allwable fee fr the physician anesthesilgist is apprtined between the tw. The anesthesilgist is reimbursed 52 percent f the fee, and the CRNA is reimbursed 48 percent f the fee. If multiple CRNAs r anesthesilgists are prviding anesthesia services fr a client, nly ne CRNA and ne anesthesilgist may be reimbursed. When a CRNA persnally perfrms the anesthesia service and is medically directed by a surgen, the CRNA is reimbursed 92 percent f the fee.
Time-Based Fees Reimbursement f time-based anesthesia services is derived frm the fllwing steps: 1. Divide the ttal anesthesia time in minutes (the time f all prcedures perfrmed, directed r supervised) by 15. 2. Add the relative value units (RVUs) fr the prcedure perfrmed (use the prcedure with the highest RVUs when multiple prcedures are perfrmed at the same time). 3. Multiply this sum by the apprpriate cnversin factr. 4. Multiply by the mdifier cmbinatin adjustment percentage The frmula fr this methdlgy is as fllws: [(Minutes/15) + RVUs] x Cnversin Factr x Mdifier Cmbinatin Adjustment = Anesthesia Reimbursement.