2007 PMCC Anesthesia Chapter 18

1. 2007 – PMCCAnesthesiaChapter 18

2. Chapter Outline Introduce students to Forms of anesthesia Anesthesia guidelines Anesthesia modifiers

3. Anesthesia Guidelines Anesthesia service includes Usual preoperative and postoperative visits Administration of the anesthetic for the site of surgery Anesthesia care during the procedure Administration of fluids and/or blood replacement Interpretation of noninvasive monitoring (blood pressure, ECG, temperature, oximetry, apnography, and mass spectrometry) Time Key element for reimbursement Starts when anesthesiologist begins preparing patient in OR Ends when anesthesiologist no longer in personal attendance and patient is safely placed under postoperative supervision

4. Anesthesia Guidelines Time continued May be reported in units based on defined time increments Most common is 15 minutes (1 unit for each 15 minutes) Medicare requires time reported in actual minutes, not units Anesthesia provided during multiple surgical procedures Reported by listing the anesthesia cod with highest base unit value and reporting total time of all procedures Separate payment allowed for selected services in conjunction with anesthesia or unrelated procedure Insertion of Swan-Ganz catheter (93503) Central venous pressure line (36555-36597) Arterial line (36620-36625)

5. Medicare Guidelines Anesthesia services Provided by or under supervision of a physician Services may include, but not limited to General or regional anesthesia Monitoring of physiological parameters during local or peripheral block anesthesia with sedation Other supportive services in order to afford the patient anesthesia care deemed optimal by the anesthesiologist during any procedure Codes describe General anatomic area or service Usually relates to a number of surgical procedures Only one anesthesia code reported unless code is an add-on code

6. Anesthesia Modifiers Three sets of modifiers to consider Physical status HCPCS CPT CPT manual also includes codes for Reporting circumstances that could increase the difficulty of providing anesthesia

7. Physical Status Modifiers P1—Normal, healthy patient P2—Patient with mild systemic disease (eg, mild, benign, hypertensive heart disease) well controlled on medication P3—Patient with severe systemic disease (eg, benign, hypertensive heart and renal disease with congestive heart and renal failure) P4—Patient with severe systemic disease that is a constant threat to life (eg, hypertrophic obstetric cardiomyopathy with ESRD) awaiting heart transplant P5– Moribund patient who is not expected to survive without surgery P6—A declared brain dead patient whose organs are being removed for donor purposes

8. CPT Modifiers 22—Unusual Procedural Services 23—Unusual Anesthesia (Identifies a procedure that usually requires no anesthesia or local anesthesia. Under unusual circumstances, general anesthesia is required) 32—Mandated Services 51—Multiple Services 53—Discontinued Procedure 59—Distinct Procedural Service (Identifies certain circumstances when a physician may need to indicate that a procedure/service was distinct or independent from other services performed on the same day)

9. HCPCS Level II Modifiers AA—Anesthesia service performed personally by anesthesiologist AD—Medical supervision by a physician: more than four concurrent anesthesia procedures G8—Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure G9—Monitored anesthesia care for patient who has history of severe cardiopulmonary condition QB—Physician providing service in a rural HPSA QK—Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QS—Monitored anesthesia care service (MAC) QX—Certified registered nurse anesthetist (CRNA) service, with medical direction by a physician QY—Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist QZ—CRNA service, without medical direction by a physician

10. Types of Anesthesia General Anesthesia Results in loss of consciousness Produces amnesia by blocking the awareness center in the brain CPT codes 00100-01999 represent general anesthesia unless code description states otherwise Regional Anesthesia Blocks all painful sensation to the specific region of the body innervated by the nerve or nerve plexus receiving the anesthetic Does not induce unconsciousness

11. Types of Anesthesia Peripheral Nerve Blocks Anesthetize individual nerves or nerve plexuses Anesthetic agent injected along the nerve rather than in the nerve Codes 64400-64530 Used to describe these services Nerve Blocks Anesthetize entire regions Spinal Anesthesia Used for major procedures performed below level of the diaphragm Relatively safe Provides excellent muscle relaxation Accomplished by placing needle between the vertebrae and injecting anesthetic agent into the subarachnoid space Frequently used for pain management by anesthesiologists

12. Types of Anesthesia Epidural Anesthesia Achieved by injecting anesthetic agent into epidural space of thoracic or lumbar interspaces Usually avoid postoperative headaches Intravenous Regional Blocks Used for some procedures on extremities Pneumatic tourniquet applied to the limb and anesthetic agent is injected into the vein of the limb distal to the tourniquet Field Block Used to form barrier between operative site and nervous system Accomplished by multiple injections of local anesthetic agent Local Anesthesia Applied topically or by local infiltration

13. Pain Management Benefits of proper pain management Shorter hospital stays Increased mobilization Acute Pain May be experienced during postoperative period Included in surgeon’s fee Should only be turned over to a specialist when special circumstances warrant this level of service Documentation must exist within medical record to indicate why services of anesthesiologist are needed

14. Pain Management Pain management options may include Cognitive, behavioral interventions such as education, relaxation, distraction, biofeedback Systemic administration of a nonsteroidal anti-inflammatory drugs (NSAID) or opiates Patient controlled analgesia (PCA) Spinal analgesia Intermittent or continuous nerve block Physical agents (eg, massage) application of heat or cold modalities Transcutaneous electrical nerve stimulator (TENS) Chronic Pain Pain that does not resolve itself after 3-6 months Treated by variety of modalities

15. Monitored Anesthesia Care (MAC) At times, an anesthesiologist may be called upon to Provide specific anesthesia services to a patient undergoing planned procedure, when patient may receive local or no anesthesia at all MAC should be reported by using Modifier QS Documentation for medical necessity Should be evident in patient’s record Medicare Wants modifier G8 or G9 to be reported, if applicable

16. Procedural Coding Spine and Spinal Cord (00600-00670) New codes for 2007 00625 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing one lung ventilation 00626 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing one lung ventilation

17. Procedural Coding Knee and Popliteal Area (01320-01444) Regional anesthesia for knee surgery has three separate steps Epidural/spinal anesthesia pain during the surgery Femoral nerve block helps to manage pain after the surgery Sedation during surgery Lower Leg (Below Knee, Includes Ankle and Foot) (01462-01522) Sciatic nerve used to numb only the leg and foot scheduled for surgery Other leg not affected When needle is close to correct position, patient’s foot will move on its own Once needle in proper position, nerve block medicine is injected

18. Procedural Coding Shoulder and Axilla (01610-01682) Nerves of should and arm Located on side of the neck, just above collarbone Single injection into nerves will numb shoulder for 12-24 hours Numbing affects only the side scheduled for surgery Radiological Procedures (01905-01933) Interventional radiology using fluoroscopy, ultrasound, CT and MRI Often performed under local anesthesia with IV sedation General anesthesia may be provided to patients who have had difficulty with sedation, or have coexisting medical conditions

19. Procedural Coding Burn Excisions or Debridement (01951-01953) Local or general anesthesia May be used when surgically debriding burns Tip: Burns in the OR—most burns (58%) in the OR are from devices used to warm the patient, including IV bags and warming devices, cautery devices caused from burns either by grounding pads or by causing a fire. Miscellaneous devices associated with burns included MRI, retractors, defibrillator paddles, and ECG leads.

20. Procedural Coding Obstetrical Anesthesia (01958-01969) Several different forms of anesthesia administered for childbirth May be used independently or in conjunction with one another Most commonly administered Local Regional

21. Qualifying Circumstances Anesthesiologists and CRNAs should use these add-on codes to report Situations that make administering anesthesia particularly difficult Medicare does not pay for the following add-on services +99100 — Anesthesia for a patient of extreme age, under one year or over 70 +99116 — Anesthesia complicated by utilization of total body hypothermia +99135 — Anesthesia complicated by utilization of controlled hypotension +99140 — Anesthesia complicated by emergency conditions (specify)

22. Moderate Conscious Sedation (99143-99150) Located in the Medicine Section of CPT Drug induced depression of consciousness Allows patient to Respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation May be administered in Hospitals Outpatient facilities

23. Moderate Conscious Sedation (99143-99150) Services that are included in moderate conscious sedation Assessment of patient (not included in intraservice time) Establishment of IV access and fluids to maintain patency, when performed Administration of agent(s) Maintenance of sedation Monitoring of oxygen saturation, heart rate, and blood pressure Recovery (not included in intraservice time) Code 99143—clarifies use of moderate conscious sedation services; sedation provided by same physician performing the diagnostic/therapeutic service, younger than 5 years of age, first 30 minutes of intraservice time Codes 99144 and 99145—further clarify age and time constraints Code 99148—clarifies use of a second provider; under age 5 years of age, first 30 minutes intraservice time

24. Anesthesia Crosswalk Anesthesia codes Do not often correspond on a one-to-one basis with surgery codes Approximately 40,000 Surgical, medical and radiological procedures represented by nearly260 anesthesia codes Anesthesia codes Arranged based on anatomical areas Important to utilize a crosswalk such as ASA Crosswalk – A Guide for Surgery/Anesthesia CPT Codes

25. The End