CHAPTER 16 ANESTHESIA Copyright 2014 by Saunders an

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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 2

Uses of Anesthesia • Relieve pain • Manage – Unconscious patients – Life functions

Methods of Anesthesia Figure: 16. 1 A Endotracheal Through mouth • ______: (Cont’d …)

Methods of Anesthesia Figure: 16. 2 • Local _____: Application to area (injection or

Methods of Anesthesia (…Cont’d) Epidural Into epidural space • _______: • Regional _______: Field or nerve – Includes spinal and epidural Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6

Patient-Controlled Analgesia (PCA) • Patient administers drug • Often used to control acute post-op

Conscious ) Sedation Moderate (_____ • Patient controls his/her airway and can respond to verbal commands • General renders the patient unconscious • Decreased level of consciousness -99150 (Medicine) • Report with 99143______ • Codes divided on: – Age > or < 5 _ – Time – Provided by physician performing service (9914399145) or other physician (99148 -99150) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8

Anesthesia Section Format Figure: 16. 4 • Anatomic divisions Copyright © 2014 by Saunders,

Anesthesia Formula • B _ +T _ +M _ 1. Base units 2. Time

B is for Base Unit • Published in RVG (Relative Value Guide®) by ASA • National unit values for anesthesia services complexity – Based on _____ – Base Unit Value (BUV) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11

Relative Value Guide® (RVG) • Lists all CPT anesthesia codes • Italicized comments added

Relative Value Guide® Figure: 16. 8 Courtesy U. S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Unit Values assigned to each code • Base ____ (Cont’d …) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13

Relative Value Guide® (…Cont’d) • Anesthesia services paid on set amount per unit (conversion factor) • Example: Medicare unit value, North Carolina in 2013 was $21. 09 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14

T is for Time • Patient record indicates time, e. g. , 15, 30, 60 minutes • Often, 15 minutes = 1 unit • 60 minutes = 4 units (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15

T is for Time (…Cont’d) • 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 16

M is for Modifying Unit • Physical condition indicated by physical status modifier • P_ 1 - P_, 6 in Anesthesia Guidelines • Risk Factor • Not reported for Medicare (Cont’d …) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17

Physical Status Modifiers, P 1 through P 6 (…Cont’d) • • P 1 P 2 P 3 P 4 Normal, healthy Mild ___ systemic disease Severe systemic disease and in constant threat to life survive without operation • P 5 Not expected to ______ • P 6 Brain ____ dead (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 18

Physical Status Modifiers (…Cont’d) • Payment differential based on some physical status ratings Copyright

Another Modifying Unit • Qualifying Circumstances, 99100 _____– 99140 • In Anesthesia Guidelines • Also in Medicine _______ section • Not reported for Medicare Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20

Qualifying Circumstances Codes and Relative Value Figure: 16. 10 Excerpted from 2013 Relative Value Guide®, © 2012 of the American Society of Anesthesiologists. All Rights Reserved. A copy of the full text can be obtained from ASA, 520 N. Northwest Highway, Park Ridge, IL, 60068 -2573. • Listed in addition to primary ______ anesthesia code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21

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 (P 1 -P 6)] • B+T+M=Total Units × $ (CF) = payment – CF = Conversion factor Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22

Conversion Factors Figure: 16. 13 • 2013 CMS Anesthesia Conversion Factors Copyright © 2014

Anesthesia for Multiple Surgical Procedures time not • Once anesthetized, length _____ of ____

Multiple Service (…Cont’d) • Example: two procedures during same session – One, 10 base unit value; the other, 5 base unit value – Report only 10 __ base unit value Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25

HCPCS Modifiers • Added to anesthesia code Anesthesiologist • -AA = Anesthesia by _______ • -AD Physician, medical supervision, 4+ concurrent procedures • -G 8 MAC (monitored anesthesia care), complex procedures • -G 9 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26