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TRANSCRIPT
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DOCUMENTING ANESTHESIA SERVICES
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC)
Provider Outreach and Education
March 21 2017
DOCUMENTING ANESTHESIA SERVICES
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC)
Provider Outreach and Education
March 21 2017
March 2017 3
Using On24 Widgets
Adjust volume using your computer speakers headset or the ON24 Media Player
Use your mouse to point click and open a widget
March 2017 4
Adjusting Your ON24 Screen View
Sometimes you may want to minimize or maximize one screen to view another
Some computers are set up to open new windows in the Full Screen view This view disables all the ribbons and toolbars and only provides you with minimal options If you are unable to see portions of todayrsquos session press the F11 key to switch from Full Screen Viewing
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
DOCUMENTING ANESTHESIA SERVICES
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC)
Provider Outreach and Education
March 21 2017
DOCUMENTING ANESTHESIA SERVICES
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC)
Provider Outreach and Education
March 21 2017
March 2017 3
Using On24 Widgets
Adjust volume using your computer speakers headset or the ON24 Media Player
Use your mouse to point click and open a widget
March 2017 4
Adjusting Your ON24 Screen View
Sometimes you may want to minimize or maximize one screen to view another
Some computers are set up to open new windows in the Full Screen view This view disables all the ribbons and toolbars and only provides you with minimal options If you are unable to see portions of todayrsquos session press the F11 key to switch from Full Screen Viewing
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
DOCUMENTING ANESTHESIA SERVICES
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC)
Provider Outreach and Education
March 21 2017
March 2017 3
Using On24 Widgets
Adjust volume using your computer speakers headset or the ON24 Media Player
Use your mouse to point click and open a widget
March 2017 4
Adjusting Your ON24 Screen View
Sometimes you may want to minimize or maximize one screen to view another
Some computers are set up to open new windows in the Full Screen view This view disables all the ribbons and toolbars and only provides you with minimal options If you are unable to see portions of todayrsquos session press the F11 key to switch from Full Screen Viewing
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 3
Using On24 Widgets
Adjust volume using your computer speakers headset or the ON24 Media Player
Use your mouse to point click and open a widget
March 2017 4
Adjusting Your ON24 Screen View
Sometimes you may want to minimize or maximize one screen to view another
Some computers are set up to open new windows in the Full Screen view This view disables all the ribbons and toolbars and only provides you with minimal options If you are unable to see portions of todayrsquos session press the F11 key to switch from Full Screen Viewing
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 4
Adjusting Your ON24 Screen View
Sometimes you may want to minimize or maximize one screen to view another
Some computers are set up to open new windows in the Full Screen view This view disables all the ribbons and toolbars and only provides you with minimal options If you are unable to see portions of todayrsquos session press the F11 key to switch from Full Screen Viewing
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 5
Disclaimer The information provided in this presentation was current as of 3212017 Any
changes or new information superseding the information in this presentation will be provided in articles and resources with publication dates after 3212017 posted on our website at wwwPalmettoGBAcomRR Medicare policy changes frequently so links to the source documents have been provided within the document for your reference
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
The Centers for Medicare amp Medicaid Services (CMS) and the Railroad Retirement Board (RRB) employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide
This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are contained in the relevant laws regulations and rulings
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 6
What is Railroad Medicare
Railroad Retirement Acts of the 1930s
First retirement system for nongovernmental workers
Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents
The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts
Part B claims for Railroad Medicare beneficiaries are processed nationally by Palmetto GBA in Augusta Georgia as the Railroad Retirement Board Medicare Specialty Administrative Contractor (RRB SMAC)
Part A and DMEPOS claims for Railroad Medicare beneficiaries are processed by jurisdictional Medicare Administrative Contractors (MACs)
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 7
Objectives
At the end of this presentation you will be familiar with
bull Medicare Part B coverage guidelines for anesthesia services related to CPT codes 00810 and 00670
bull Medicarersquos documentation requirements for anesthesia services related to moderate sedation and general anesthesia
bull Medical review of anesthesia services on CPT codes 00810 and 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 8
Agenda
Overview of Medical Review Program
Medicare Coverage of Anesthesia Services
Anesthesia Billing Requirements
Documentation of Anesthesia Services bull CPT 00810
bull CPT 00670
Review Results
Resources
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 9
MEDICAL REVIEW
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 10
Railroad Medicare Medical Review Program
Supports the goals of the CMS Medical Review program Proactively identifies patterns of potential billing errors
concerning coverage and coding Reviews data analysis reports complaints or inquiries Takes action to prevent andor address the identified
errors Develops and conducts education The goal of the medical review (MR) program is to
reduce payment errors by preventing the initial payment of claims that do not comply with Medicarersquos coverage coding payment and billing policies
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 11
Railroad Medicare Prepayment Medical Review
Performed as a result of vulnerabilities determined by data analysis
Performed on claims prior to payment
Results in an initial determination
Service-specific (CPTHCPCS)
Widespread
Additional Documentation Requests (ADRs) are sent to request supporting documentation
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 12
Prepayment Review Process Claim is selected for review Additional Documentation Request (ADR)
letter is issued You must respond within 45 calendar days Medical Review will make a determination
within 30 calendar days of receiving requested documentation Claim will be denied on the 46th day is a
response is not received
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 13
Medical Record Requests Medicare contractors are authorized to collect medical documentation
by the Social Security Act Section 1833(e) states
ldquoNo payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodrdquo These requirements are also outlined in Section 1815(a) of The Act
Providing medical records of Medicare patients to the RRB SMAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA)
Medicare contractors are not required to pay for medical documentation for either prepayment or postpayment review
Documentation will be requested from the rendering provider
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 14
How to Respond to an ADR
Provide the documents listed on the ADR and any related physicianrsquos orders
Make sure the providerrsquossignature is legible or include a signature log or attestation if necessary
Include a copy of the ADR letter with your documents or
Include a completed lsquoMedical Review ADR Response Cover Sheetrsquo for each ADR letterclaim
When returning ADR responses for multiple claims be sure to pair each ADR letter with the corresponding documentation
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 15
Methods of Responding Respond in one of the following ways Upload your documentation online through
eServices Submit your documentation via the esMD (Electronic
Submission of Medical Documentation) mechanism See wwwcmsgovesmd for details
Fax your responses to 803-264-8832 Mail documents or an encrypted CDDVD Mail responses to
Palmetto GBA Railroad Medicare Medical Review PO Box 10066
Augusta GA 30999
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 16
Granular Denial Letters
Claim Review Decision and Education Letter
Sent when claim is denied by Medical Review
Explains why claim was denied
Outreach and Education may contact providers to discuss review findings
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 17
Medical Review Webcast
Recorded presentation available
Look for Webinars amp Workshops on our Learning amp Education Page
wwwPalmettoGBAcomRR
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 18
MEDICARE COVERAGE OF ANESTHESIA TYPES
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 19
Definition of Anesthesia
Anesthesia is medication administration to produce a blunting or loss of Pain perception (analgesia) Voluntary and involuntary movements Autonomic function Memory andor consciousness
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 20
Types of Anesthesia
Anesthesia types range in complexity from General anesthesia Regional anesthesia Moderate (conscious) sedation Minimal sedation Local or topical anesthesia
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 21
General Anesthesia
General Anesthesia is drug-induced loss of consciousness Patient is usually not arousable even by painful
stimulation Independent ventilation is often impaired Cardiovascular function my be impaired
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 22
Regional Anesthesia
Regional Anesthesia is the delivery of anesthetic medication to the spinal cord andor to peripheral nerves Used when loss of consciousness is not desired
Requires analgesia Leads to loss of voluntary and involuntary
movement
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 23
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) includes monitoring by a practitioner qualified to administer anesthesia Ability to independently maintain respiratory function
may be impaired Cardiovascular function is usually maintained Usually begins as deep sedationanalgesia Potential for progression to general anesthesia
requires a practitioner qualified in delivery of anesthesia
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 24
Moderate Sedation Moderate sedation (ldquoConscious Sedationrdquo) is a drug-induced depression of consciousness Patients respond purposefully to verbal commands
either alone or accompanied by light tactile stimulation
Does not include minimal sedation deep sedation or monitored anesthesia care
No interventions are required to maintain a patent airway and spontaneous ventilation is adequate
Cardiovascular function is maintained
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 25
Minimal Sedation
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands Cognitive function and coordination may be
impaired Respiratory and cardiovascular functions are
independently maintained
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 26
Topical or Local Anesthesia
Topical or local anesthesia is the application or injection of a drug or combination of drugs to stop or prevent a painful sensation to a circumscribed area of the body where a painful procedure is to be performed No systemic effects of these medications Usually included in the procedure performed
not separately payable by Medicare
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 27
Reasons for Non-Coverage of Anesthesia
Anesthesia is not separately payable when Included in the associated procedurersquos pricing
bull Use of ldquocainerdquo drugs ndash lidocaineprocaine
Associated procedure is not reasonable and necessary bull Investigational or experimental procedures
Associated surgeryservice is not covered bull Non-covered dental and cosmetic services
This is not an all-inclusive listing
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 28
Review of CPT 00810
CPT 00810 - anesthesia for lower intestinal endoscopic procedures endoscope introduced distal to duodenum Moderate Sedation Used by anesthesia providers ndash anesthesiologist
CRNA AA Usually this code is billed for anesthesia related to
colonoscopy procedures
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 29
Review of CPT 00670
CPT 00670 - anesthesia for extensive spine and spinal cord procedures (such as spinal instrumentation or vascular procedures) General anesthesia Associated with surgery that includes
bull Instrumentation (placement or removal of hardware) or
bull Multiple vertebral segments
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 30
BILLING AND CODING
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
bull Head 00100-00222 bull Knee and Popliteal Area 01320-01444 bull Neck 00300-00352 bull Lower leg (below knee includes ankle bull Thorax (chest and shoulder) 00400shy and foot) 01462-01522
00474 bull Shoulder and Axilla 01610-01682 bull Intrathoracic 00500-00580 bull Upper Arm and Elbow 01710-01782 bull Spine and Spinal Cord 00600-00670 bull Forearm Wrist and Hand 01810shybull Upper Abdomen 00700-00797 01860
bull Lower Abdomen 00800-00882 bull Radiological Procedure 01916-01936
bull Perineum 00902-00952 bull Burn Excisions or Debridement
bull Pelvis (excludes hip) 01112-01190 bull Upper (excludes knee) 01200-01274
bull
bull
01951-01953 Obstetric 01958-01969 Other Procedures 01990-01999
March 2017 31
Anesthesia CPT Codes 00100-01999 Organized by body partarea Bill with appropriate anesthesia modifier(s)
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 32
Anesthesiology Provider Performance
Types of anesthesiology provider performance Personally Performed Medically Directed Medically Supervised
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 33
Personally Performed Rate The physician personally performed rate should be billed if
The physician personally performed the entire anesthesia service alone
The physician is involved with one anesthesia case with a resident the physician is a teaching physician
The physician is involved in the training of physician residents in a single anesthesia case two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules
The physician is continuously involved in a single case involving a student nurse anesthetist
The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 34
Medically Directed Rate Medical direction occurs if the physician medically directs qualified individuals in two three or four concurrent cases and the physician performs the following activities
Performs a pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
Monitors the course of anesthesia administration at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies and
Provides indicated-post-anesthesia care
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 35
Medically Supervised Rate
The contractor may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures
An additional time unit may be recognized if the physician can document he or she was present at induction
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 36
Anesthesia Pricing Modifiers Report the appropriate modifier to denote whether the service was
personally performed medically directed or medically supervised Submit pricing modifier in first modifier field
Modifier Description AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician more than 4 concurrent
anesthesia procedures QY Medical direction of one qualified nonphysician anesthetist by an
anesthesiologist QK Medical direction of 2 3 or 4 concurrent anesthesia procedures
involving qualified individuals QX Qualified nonphysician anesthetist with medical direction by a
physician QZ CRNA without medical direction by a physician
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 37
QZ Anesthesia Pricing Modifier
QZ - CRNA service without medical direction by a physician In 2001 CMS created a new rule to allows states to opt
out of the physician supervision requirement for CRNAs
Only the Territory of Guam and seventeen states have opted out to allow CRNAs to practice independent service Alaska California Colorado Iowa Idaho Kansas Kentucky Minnesota Montana Nebraska New Hampshire New Mexico North Dakota Oregon South Dakota Washington and Wisconsin
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 38
Anesthesia Care Modifiers If applicable use in addition to appropriate anesthesia pricing modifier
Modifier Description
QS Monitored anesthesia care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)
G8 MAC for deep complex complicated or markedly invasive surgical procedure
G9 MAC for patient who has history of severe cardiopulmonary condition
GC This service has been performed in part by a resident under direction of a teaching physician
23 Unusual anesthesia
Do not bill Patient Status modifiers P1 - P6 to Medicare
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 39
CPT Modifier 47 - Anesthesia by Surgeon May be submitted on the basic service when operating
surgeon performs regional or general anesthesia
No separate Medicare allowance for anesthesia ndash included in surgeonrsquos payment for procedure
Not used for bull Anesthesia services provided by anesthesiologistCRNAAA
bull CPT codes 00100 through 01999
bull Local anesthesia
bull Moderate sedation codes 99143 through 99145
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 40
Anesthesia Time and Time Units
Actual anesthesia time in minutes is reported on the claim
bull Convert hours to minutes (ex 1 hour 35 minutes = 95 total minutes)
bull Enter total minutes in block 24G of the CMS-1500 form or the equivalent EMC field
RRB SMAC computes time units by dividing reported anesthesia time by 15 minutes Round the time unit to one decimal place
Time units not recognized for CPT codes 01995 or 01996
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 41
Anesthesia Payment Anesthesia services are reimbursed differently from other
procedure codes
bull Base Units ndash assigned to CPT codes by CMS
bull Time Units ndash Time the patient was lsquounder anesthesiarsquo
bull Conversion Factor (CF) - CMS releases locality specific CFs annually
Formula for calculating allowed amount for anesthesia
(Base Units + Time (in units)) x CF = Anesthesia Fee Amount
Links to Base Units by CPT code files and Conversion Factor files available on CMS Anesthesiologists Center page at wwwCMSgov
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 42
Anesthesia Reimbursement Rates
Payment for services that meet the definition of personally performed is based on the base units (as defined by CMS) and time in increments of 15-minute units
Services that are medically directed are reimbursed at 50 percent of the personally performed rate
Payment for services that are medically supervised is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 43
Billing for Multiple Anesthesia Procedures
Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures
Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures
An example of this is when a patient has multiple procedures of endoscopy and colonoscopy performed under single induction event ndash anesthesia specialist could bill the 00810 for both procedures with the combined time of both procedures
The reimbursement would be based on the base for the 00810 and the total time of the anesthesia service
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 44
DOCUMENTATION
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 45
Documentation Requirements - General When responding to an Additional Documentation Request for an anesthesia service
Include a copy of the ADR letter with your documents
Provide the documents listed on the ADR or the Anesthesia checklist and any other supportive documents
Ensure the following are easily identifiable with the documentation submitted
bull Beneficiary Name on all documentation
bull Date of Service
bull Appropriate CPT code(s) Billed
bull Appropriate Modifier(s) Billed
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 46
Documentation Requirements - General All documentation should also include
bull Documentation to support the physician was available during the anesthesia monitoring if billed with the QK QX or QY modifier
bull Signatures that follow the Medicare guidelines
bull Abbreviation key (if applicable)
bull Signature attestation (if applicable)
All documentation including signatures should be complete and legible
bull If your documentation is illegible a transcribed note or an amendment signed by the rendering provider are helpful
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 47
Signatures on Orders and Records Must include a legible form of the name and credentials
Printed or typed names must be accompanied by initials or signature of provider
Electronic signatures must indicate it is an electronic signature
Signature examples
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 48
Medicare Signature Requirements
Medicare has established signature guidelines
This reference is provided to help you find answers to questions about Medicare signature requirements
httptinyurlcom905364
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 49
Documentation - Moderate Sedation
For Moderate Sedation the following is required bull Documentation indicating anesthesia start and
stop time or total anesthesia time bull An order for drugs used or documentation of the
drug administration bull Valid signature(s) of the rendering provider(s)
Moderate sedation code under medical review shyCPT 00810
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 50
Moderate Sedation Exemption
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before during and after the procedure by trained practitioners Moderate sedation is not considered to be
ldquoanesthesiardquo so it is exempt from requirement for the pre-anesthesia and post-anesthesia evaluations
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 51
Documentation ndash General Anesthesia General AnesthesiaMonitored Anesthesia records should
include
bull Pre-Anesthesia Evaluation performed within 48 hours prior to surgery or procedure requiring anesthesia services
bull Intra-Operative Anesthesia Record
bull Post-Anesthesia Evaluation completed no later than 48 hours after surgery or procedure requiring anesthesia services
bull Anesthesia start and stop times
bull Valid signature(s) of the rendering provider(s)
General Anesthesia code under medical review ndash CPT 00670
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 52
Pre-Anesthesia Evaluation Elements The pre-anesthesia evaluation should be updated within 48 hours prior to the delivery of the anesthesia and should include
An interview with the patientguardian to review history bull Medical ndash comorbidities medications allergies bull Previous anesthesia reactionscomplications
An appropriate physical examdiagnostic review bull ABCs - Airway Breathing Circulation Fasting Labs EKG x-ray
Identification of potential anesthesia complications or contraindications to the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Development of the plan for the patientrsquos anesthesia care bull Medications for induction maintenance and post-operative care
Discussion of anesthesia benefits and possible risks
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 53
Pre-Anesthesia Evaluation Elements An interview with the patientguardian to review history Identification of potential anesthesia complications or contraindications to
the planned procedure (eg difficult airway ongoing infection limited intravascular access)
Discussion of anesthesia benefits and possible risks Updated within 48 hours prior to the delivery of the anesthesia
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 54
Pre-Anesthesia Evaluation Elements An appropriate physical examdiagnostic review ABCs - Airway Breathing Circulation NPO status ndashFasting Labs EKG x-ray
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 55
Pre-Anesthesia Evaluation Elements
Medical
bull Comorbidities
bull Medications
bull Allergies
Previous anesthesia reactionscomplications
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 56
Pre-Anesthesia Evaluation Elements
Development of the plan for the patientrsquos anesthesia care
Medications for induction maintenance and postshyoperative care
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 57
Intra-Operative Anesthesia Record Elements Start and stop time of the anesthesia service
Name and identification number of the patient
Name(s) or practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
Techniques(s) used and patient position(s) ndash includes the insertion or use of any intravascular or airway devices
Name and amounts of IV fluids including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 58
Intra-Operative Anesthesia Record Elements
Anesthesia Record Patient Cathy Collie
MRN 111222333
DOB 1011935 Sex F
CRNA Charles Spaniel CRNA
Surgeon Sue Shepherd MD
Anesthesiologist Bill Boxer MD
Name and identification number of the patient
Name(s) of practitioner(s) who administered anesthesia
Name and profession of the supervising anesthesiologist or operating practitioner (as applicable)
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 59
Intra-Operative Anesthesia Record Elements Techniques used and patient
Start and stop time of the position(s) ndash includes the anesthesia service insertion or use of any
intravascular or airway devices
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 60
Intra-Operative Anesthesia Record Elements Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Name and amounts of IV fluids including blood or blood products if applicable
Any complications adverse reactions or problems occurring during anesthesia including time and description of problems vital signs treatments rendered and the patientrsquos response to treatment
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 61
Intra-Operative Anesthesia Record Elements Name and Dosage of drug and anesthesia agents
Route and time of administration of drugs and anesthesia agents
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 62
Post-Anesthesia Evaluation Elements The post-anesthesia evaluation should be completed within 48 hours after anesthesia and should include Respiratory function including respiratory rate airway patency
and oxygen saturation Cardiovascular function including pulse rate and blood
pressure Mental status Temperature Pain Nausea and vomiting and Postoperative hydration Patient should be recovered enough to participate in the
evaluation by answering questions appropriately performingsimple tasks etc
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 63
Post-Anesthesia Evaluation Example
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 64
The Physician of Record If anesthesiologists are in a group practice one physician
member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria
Similarly one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service
The medical record must indicate the services furnished and identify the physicians who furnished them
Only one member of the group would bill for the entire anesthesia service This should be the provider who initiated the care or who spent the most time in the case
Signatures of the CRNAAA and the overseeing anesthesiologist(s) should be included in the records
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 65
Medical Necessity of Service
Medical necessity is defined as those services that are reasonable and necessary for thediagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Medical necessity is supported by
bull Utilization of the appropriate billing code bull Applicable modifier bull Clinical documentation supporting the diagnosisand necessity
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 66
Documentation Checklist ndash Anesthesia
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 67
REVIEW RESULTS
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 68
Widespread Review Results 1st Quarter 2017 Palmetto GBARailroad Medicare has completed a
widespread review of claims submitted between October and December 2016 for CPT codes 00670 and 00810
Based on the dollar amount billed the combined overall error rate is 542
CPT Codes Services Services Services Error Rate Reviewed Allowed Denied by Dollar
Amount 00670 530 168 362 679
00810 4497 2256 2241 483
Totals 5027 2424 2603 542
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 69
Top Denials CPT 00670
Number ofDenial Reason Denials
Non-Response 190
Percentage 525
Insufficient 160 Documentation
Percentage 442
Signature 3
Percentage lt1
CPT 00810 Number ofDenial Reason Denials
Non-Response 1550
Percentage 689
Insufficient 434 Documentation
Percentage 194
Signature 195
Percentage 87
CPT codes descriptors and other data only are copyright 2016 American Medical Association All rights reserved
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 70
Non-Response to ADRs
Represents greatest number of claim denials No response received Response received more than 45 days after date of request
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 71
Insufficient Documentation Denials
Illegibility - If document is not readable due to copy quality or provider handwriting it can be difficult or impossible to find the elements necessary to support the service
Missing Pre- andor Post- Anesthesia Evaluations This documentation is usually separate from the Intra-Operative report Medicare guidelines require these elements for General Anesthesia or Monitored anesthesia care
Missing Time - Documentation of the Start and Stop times of the Anesthesia Care should be included and clearly documented
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 72
Other Denials
No Documentation - The denial would be based on no documentation of the service that was billed This might be the case if the submission contained the Operative Report from the surgeon but was missing the Anesthesia Record
Wrong Documentation - Sometimes the records submitted are for a different anesthesia service a different beneficiary or a different date of service
No Order - This denial reason indicates no doctor order for the anesthesia medications used or the medications were not listed in the anesthesia record
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 73
Signature Denials
Signature Issues - The rendering provider signature must follow Medicare guidelines It should be clear that the signature is that of the person identified as the rendering provider in the claim
Some common issues are
bull Missing signature
bull Illegible signature
bull No signature log or attestation
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 74
RESOURCES
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 75
Anesthesia Resources CMS Internet Only Manual (IOM) 100-04 Medicare Claims
Processing Manual Chapter 12 - PhysicianNonphysician Practitioners
bull sect50 Payment for Anesthesia Services
bull sect140 Qualified Nonphysician Anesthetist Services
bull sect100 Teaching Physician Services
CMS MLN ICN 901623 ndash Advanced Practice Registered Nurses Anesthesiologist Assistants and Physician Assistants
CMS - Anesthesiologists Center httpswwwcmsgovCenterProvider-TypeAnesthesiologistsshyCenterhtml
Electronic Code of Federal Regulations 42 CFR 48252 Condition of Participation Anesthesia Services
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 76
MLN Resources The Medicare Learning Networkreg Page
httptinyurlcomMLNPage
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 77
MLN Connectsreg National Provider Calls Free educational conference calls held by CMS for the
Medicare providers and suppliers to educate and inform about new policies andor changes to the Medicare program
Prior registration is required
Subscribe to weekly MLN Connectsreg Provider eNews newsletter to receive the latest Medicare program information including MLN National Provider Calls announcements
httptinyurlcomMLNCalls
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 78
CMS Open Door Forums
CMS sponsors regularly scheduled lsquoOpen Door Forumsrsquo providing opportunities for live dialogue between CMS and the stakeholder community at large
Subscribe to the Open Door Forum Mailing List to be notified when forums are scheduled or when new information is posted to the website
CMS Open Door Forums page httptinyurlcomOpenDoorForums
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 79
RRB SMAC Resources
wwwPalmettoGBAcomRR
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 80
RRB SMAC Resources
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 81
Visit wwwPalmettoGBAcomRR
MLN articles from the Centers for Medicare amp Medicaid Services (CMS)
Articles and FAQs by topic Self-Services Tools eServices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup ReasonRemark Code Lookup
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 82
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
wwwpalmettogbacomeServices
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 83
Respond to ADRs in eServices
Respond to Medical Review ADR and postpayment review notification letters through eServices using the MR ADR Response secure eForm
Attach an unlimited number of PDF files to each form Each attachment can be up to 40 MB The total size of all attachments on each ADR eForm can be no more than 150 MB
Track submission of your ADRs
Must have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA Railroad Medicare
Enroll for eServices at wwwpalmettogbacomeServices
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 84
Greenmail through eServices
Receive eDelivery of Provider Administrators may select the eDeliverybull Medical Review ADRs option to receive for prepayment reviews bull eLetters in eServices bull Overpayment Demand inboxletters bull email notification ofbull Medicare new eLettersRedetermination Notices
for your appeal requests
bull Responses to General Correspondenceinquiries
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 85
eServices Resources
wwwPalmettoGBAcomeServices
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 86
Stay Connected With Ushellip Join our listserv at wwwPalmettoGBAcomRR Stay Connected section Choose lsquoSign up for our Listservrsquo and select the topics you want to receive
updates on Facebook Twitter YouTube
eChat
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
RAILROAD MEDICARE RESOURCES Railroad
Medicare Homepage
wwwPalmettoGBAcomRR
Palmetto GBA Listserv
wwwPalmettoGBAcomRR Select lsquoListservsrsquo from top tool bar
Contact Us By Email MedicareRailroadPalmettoGBAcom
eServices
wwwpalmettogbacomeServices
wwwPalmettoGBAcomRR Under FormsTools
CMS Listserv httptinyurlcomCMSEmailUpdates
87March 2017
Railroad Medicare Contacts Provider Contact Center
EDI eServices Telephone Reopenings
Provider Enrollment
888-355-9165
Interactive Voice Response (IVR)
877-288-7600
Palmetto GBA Railroad Medicare
PO Box 10066 Augusta GA 30999
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 88
Questions
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom
March 2017 89
Thank you
Questions about this webcast
Provider Contact Center 1-888-355-9165
MedicareRailroadPalmettoGBAcom