UnitedHealthcare Anesthesia Policy Update
March 2019 ~
UnitedHealthcare (UHC) has issued Anesthesia Policy updates to address reimbursement of procedural or pain management services that are an integral part of anesthesia services as well as anesthesia services that are an integral part of procedural services.
According to UHC, anesthesia services must be submitted with a CPT® anesthesia code in the range 00100-01999, excluding 01953 and 01996, and are reimbursed as time-based using the Standard Anesthesia Formula. For purposes of this policy, the code range 00100-01999 specifically excludes 01953 and 01996 when referring to anesthesia services. CPT® codes 01953 and 01996 are not considered anesthesia services because, according to the ASA Relative Value Guide (RVG®), they should not be reported as time-based services.
Reimbursement Formula Updates
Base Values: Each CPT® anesthesia code is assigned a Base Value by the ASA, and UnitedHealthcare uses these values for determining reimbursement. The Base Value of each code is comprised of units referred to as the Base Unit Value.
Time Reporting: Consistent with CMS guidelines, UnitedHealthcare requires time-based anesthesia services be reported with actual Anesthesia Time in one-minute increments. For example, if the Anesthesia Time is one hour, then 60 minutes should be submitted.
Reimbursement Formulas: Time-based anesthesia services are reimbursed according to the following formulas:
Standard Anesthesia Formula without Modifier AD = ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage.
Standard Anesthesia Formula with Modifier AD = ([Base Unit Value of 3 + 1 Additional Unit if anesthesia notes indicate the physician was present during induction] x Conversion Factor) x Modifier Percentage.
Qualifying circumstances codes identify conditions that significantly affect the nature of the anesthetic service provided. Qualifying circumstances codes should only be billed in addition to the anesthesia service with the highest Base Unit Value. The Modifying Units identified by each code are added to the Base Unit Value for the anesthesia service according to the above Standard Anesthesia Formula.
Multiple or Duplicate Anesthesia Services
Multiple Anesthesia Services: According to the ASA, when multiple surgical procedures are performed during a single anesthesia administration, only the single anesthesia code with the highest Base Unit Value is reported. The time reported is the combined total for all procedures performed on the same patient on the same date of service by the same or different physician or other qualified health care professional. Add-on anesthesia codes (01953, 01968 and 01969) are exceptions to this and are addressed in the Anesthesia Services section and Obstetric Anesthesia Services section of this policy. UnitedHealthcare aligns with these ASA coding guidelines. Specific reimbursement percentages are based on the anesthesia modifier(s) reported.
Duplicate Anesthesia Services: When duplicate (same) anesthesia codes are reported by the same or different physician or other qualified health care professional for the same patient on the same date of service, UnitedHealthcare will only reimburse the first submission of that code. However, anesthesia administration services can be rendered simultaneously by an MD and a CRNA during the same operative session, each receiving 50% of the Allowed Amount (as indicated in the Modifier Table above) by reporting modifiers QK or QY and QX.
In the event an anesthesia administration service is provided during a different operative session on the same day as a previous operative session, UnitedHealthcare will reimburse one additional anesthesia administration appended with modifier 59, 76, 77, 78, 79 or XE. As with the initial anesthesia administration, only the single anesthesia code with the highest Base Unit Value should be reported.
Anesthesia and Procedural Bundled Services
UnitedHealthcare sources anesthesia edits to methodologies used and recognized by third party authorities when considering procedural or pain management services that are an integral part of anesthesia services, and anesthesia services that are an integral part of procedural services. Those methodologies can be Definitive or Interpretive. A Definitive source is one that is based on very specific instructions from the given source. An Interpreted source is one that is based on an interpretation of instructions from the identified source (see the Definitions section below for further explanations of these sources). Where CMS NCCI edits exist these edits are managed under the UnitedHealthcare “CCI Editing Policy”.
Procedural/pain management services or anesthesia services that are identified as bundled (integral) are not separately reimbursable when performed by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service. The Same Individual Physician or Other Qualified Health Care Professional is defined as the same individual rendering health care services reporting the same Federal Tax Identification number.
Procedural or Pain Management Services Bundled in Anesthesia Services:
- Services in the CMS National Physician Fee Schedule that have a status indicator of B (Bundled code) or T (Injections);
- Services that are not separately reimbursed with anesthesia services as stated in the CMS NCCI Policy Manual, Chapter 2 although they are not specifically listed in that manual: 64561, 82800, 82803, 82805, 82810, 85345, 85347, 85348;
- Nerve Block codes billed in conjunction with anesthesia services when modifier 59, XE or XU is not appended to the nerve block code
The above CPT® and HCPCS codes are included in the following list:
2019 Procedural or Pain Management Codes Bundled into Anesthesia
The CMS NCCI Policy manual states that “many standard preparation, monitoring, and procedural services are considered integral to the anesthesia service. Although some of the services would never be appropriately reported on the same date of service as anesthesia management, many of these services could be provided at a separate patient encounter unrelated to the anesthesia management on the same date of service.” Anesthesia Professionals may identify these separate encounters by reporting a modifier 59, XE or XU. For CPT® and HCPCS codes included on the Procedural or Pain Management Codes Bundled into Anesthesia list that will be considered distinct procedural services when modifier 59, XE or XU is appended, refer to the following list: 2019 Procedural or Pain Management Bundled Codes Allowed with Modifiers
Anesthesia Services Bundled in Procedural Services: According to the NCCI Policy Manual, Chapter 1, CMS does not allow separate payment for anesthesia services performed by the physician who also furnishes the medical or surgical procedure, excluding Moderate Sedation. In these situations, the allowance for the anesthesia service is included in the payment for the medical or surgical procedure. In addition, AMA states “if a physician personally performs the regional or general anesthesia for a surgical procedure that he or she also performs, modifier 47 would be appended to the surgical code, and no codes from the anesthesia section would be used.”
UnitedHealthcare will not separately reimburse an anesthesia service when reported with a medical or surgical procedure (where the anesthesia service is the direct or alternate crosswalk code for the medical or surgical procedure) submitted by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service. For medical/surgical procedures reported using CPT® codes, the direct and alternate crosswalk anesthesia codes are obtained from the ASA CROSSWALK®. For medical/surgical procedures reported as HCPCS codes, the direct and alternate crosswalk anesthesia codes are obtained from CMS NCCI edits and interpretation of other CMS sources. A listing of interpretive edits titled “Anesthesia Services Bundled into HCPCS Procedural Codes” can be found in the Attachments section below.
Consistent with CMS, UnitedHealthcare will not separately reimburse an E/M service (excluding critical care CPT® codes 99291-99292) when reported by the Same Specialty Physician or Other Qualified Health Care Professional on the same date of service as an anesthesia service.
Critical care CPT® codes 99291-99292 are not considered included in an anesthesia service and will be separately reimbursed.
The Same Specialty Physician or Other Qualified Health Care Professional is defined as physicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.
Daily Hospital Management
Daily hospital management of epidural or subarachnoid drug administration (CPT® code 01996) in a CMS place of service 19 (off campus outpatient hospital), 21 (inpatient hospital), 22 (on campus outpatient hospital) or 25 (birthing center) is a separately reimbursable service once per date of service excluding the day of insertion. CPT® code 01996 is considered included in the pain management procedure if submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional.
If the anesthesiologist continues with the patient’s care after discharge, the appropriate Evaluation and Management code should be used.
Obstetric Anesthesia Services
Neuraxial Labor Analgesia Reimbursement Calculations
Consistent with a method described in the ASA RVG® UnitedHealthcare will reimburse neuraxial labor analgesia (CPT® code 01967) based on Base Unit Value plus Time Units subject to a cap of 435 minutes. Modifying Units for physical status modifiers and qualifying circumstance codes will be considered in addition to the Base Unit Value for labor or delivery anesthesia services in accordance with the Standard Anesthesia Formula.
Obstetric Add-On Codes
UnitedHealthcare will consider for reimbursement, add-on CPT® codes 01968 and 01969 (c- section anesthesia) when billed with the primary CPT® code 01967 (by the same or different individual physician or other qualified healthcare professional) for the same member. According to the ASA Crosswalk® time for add-on code 01968 or 01969 is reported separately as a surgical anesthesia service and is not added to the time reported for the labor anesthesia service.
Obstetric Anesthesia: Neuraxial Labor Analgesia Reimbursement Calculations
Example 1: 200 minutes are reported for labor and delivery services on a single claim line with CPT® code 01967: The total 200 minutes will be added to the Base Unit Value for CPT® code 01967.
Example 2: 500 minutes are reported for labor and delivery services on a single claim line with CPT® code 01967: A capped 435 minutes will be added to the Base Unit Value for CPT® code 01967.
Example 3: Labor and delivery services are reported on multiple claim lines with CPT® code 01967 at 200 minutes and add-on CPT® code 01968 at 75 minutes: 200 minutes will be added to the Base Unit Value for CPT® code 01967 and 75 minutes will be added to the Base Unit Value for CPT® code 01968.
Example 4: Labor and delivery services are reported on multiple claim lines with CPT® code 01967 at 700 minutes, add-on CPT® code 01968 at 75 minutes, and qualifying circumstance code 99140: A capped 435 minutes for CPT® code 01967 and 30 minutes for qualifying circumstance code 99140 will be added to the Base Unit Value for CPT® code 01967 and 75 minutes will be added to the Base Unit Value for CPT® code 01968.
CPT® is a registered trademark of the American Medical Association.
Source(s): UnitedHealthcare Anesthesia Policy, Professional;