5160-4-21 Anesthesia services.

(A) The department will reimburse a physician for general, regional, or supplementation of local anesthesia services (or monitored anesthesia care services as described in paragraph (I) of this rule) provided during a surgical or diagnostic procedure. Anesthesia services include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the basic monitoring procedures. ECG, temperature, blood pressure, oximetry, capnography and mass spectometry are considered usual monitoring procedures. Unusual monitoring procedures such as intra-arterial, central venous and Swan Ganz are not included in the payment for anesthesia services and may be separately billed and reimbursed.

(B) Reimbursement for anesthesia services is the lesser of the provider's billed charge or the medicaid maximum payment as specified in paragraph (J)(5) of rule 5101:3-1-60 of the Administrative Code for services provided before May 1, 2001. For services provided on or after May 1, 2001, reimbursement for anesthesia services will be the amount obtained using the following formula:

Except for the exceptions set forth in paragraph (B) (7) of this rule, the formula for calculating the reimbursement of anesthesia services will be the base unit value and the time unit value multiplied by the appropriate conversion factor or percentage of a conversion factor as set forth in rule 5101:3-4-21.2 of the Administrative Code.

(1) "Base unit" means the value for each anesthesia code that reflects all activities other than anesthesia time. Anesthesia activities include usual pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia care, and monitoring services.

(2) "Base unit value" means the value for a base unit for each anesthesia code. These values are taken from the 200001/01/2007 American society of anesthesiologists' relative value guide. For purposes of medicaid reimbursement, base unit values from the American society of anesthesiologists will be used for anesthesia codes. For any anesthesia code covered by the department, the department will use the base unit value assigned by the American society of anesthesiologists for the year that the code was added.

(3) "Time unit" means the continuous actual presence of the physician (or of the medically-directed resident or medically-directed CRNA/AA) and starts when he/she begins to prepare the patient for anesthesia and ends when the anesthesiologist (or medically-directed CRNA/AA) is no longer in personal attendance with the exception of anesthesia for neuraxial analgesia for obstetrical services defined in paragraph (C) of rule 5101:3-4-21.1 of the Administrative Code.

(4) "Anesthesia time" is the actual number of anesthesia minutes as reported on the claim. Anesthesia time is defined in paragraph (D) (3) of this rule.

(5) "Time unit value" means one unit for each fifteen minutes of reported anesthesia time. Since only the actual time of a fractional time unit is recognized, the resulting time unit value will be rounded to one decimal place.

(6) Anesthesia conversion factors are specified in rule 5101:3-4-21.2 of the Administrative Code.

(7) The following formula exceptions apply:

(a) Anesthesia code 01996 will be paid based on the base units specified in the relative value guide. No calculation for time is allowable for this anesthesia code; and

(b) Services billed with the "AD" modifier will be paid at three times the conversion factor set forth in rule 5101:3-4-21.2 of the Administrative Code.

(C) The department will reimburse a physician for anesthesia services only if all of the following conditions are met.

(1) Except as provided for in paragraph (C)(5) of this rule, the physician is acting exclusively as an anesthetist and is not also acting as the surgeon or assistant surgeon;.

(2) For each patient, the physician:

(a) Performs a pre-anesthetic examination and evaluation;

(b) Prescribes the anesthesia plan;

(c) Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;

(d) Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual;

(e) Monitors the course of anesthesia administration at frequent intervals;

(f) Remains physically present and available for immediate diagnosis and treatment of emergencies; and

(g) Provides indicated post-anesthetic care.

(3) The physician either personally performs the services itemized in paragraph (C)(2) of this rule, without the assistance of a CRNA/AA, resident, intern, fellow, or other qualified anesthetist; or the physician uses assistance of a CRNA/AA, resident, intern, fellow or other qualified anesthetist in the performance of the services in paragraph (C)(2) of this rule, and does not perform any other services while providing medical direction.

(a) "Medical direction" is when a physician meets the requirement set forth in paragraph (C) (1) of this rule and the physician utilizes the assistance of a CRNA/AA, resident, intern, or fellow in the performance of the services listed in paragraph (C) (2) of this rule and is involved in no more than four concurrent anesthesia cases;.

(b) "Medical supervision" is when the physician meets the requirement set forth in paragraphs (C)(1), (C)(2)(a) and (C)(2)(b) of this rule and the physician anesthesiologist is involved in furnishing services for more than four concurrent procedures or is performing other services while directing the concurrent procedures.

(4) In situations where the physician is involved in medically supervising more than four procedures concurrently, or is performing other services while directing the concurrent procedures, the physician must be involved in the pre-surgical anesthesia services.

(5) When a surgeon or a group practice of surgeons employs CRNA to provide anesthesia services, the physician or group practice may bill and receive reimbursement for the services of the CRNA in addition to the reimbursement for the surgical procedures performed by the physician.

(D) For reimbursement the physician must bill the appropriate anesthesia code for the service provided modified by the appropriate anesthesia modifier, and report the anesthesia time in minutes.

(1) The following anesthesia modifiers must be used for billing anesthesia services:

AA Anesthesia services personally performed by the anesthesiologist;

AD Medical supervision by a physician: more than four concurrent anesthesia procedures;

QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals;

QX CRNA with medical direction by a physician or anesthesia assistant with medical direction by an anesthesiologist;

QY Medical direction of one CRNA by an anesthesiologist; and

QZ CRNA without medical direction by physician.

Note: Anesthesiologist assistants may use the modifier "QX" to bill for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may bill the "QY" modifier if he/she provides medical direction to an anesthesiologist assistant.

(2) Except as provided for in paragraph (H) of this rule, reimbursement for the services of a CRNA/AA may not be made to a provider of physician services, including hospitals.

(a) Services of a hospital employed CRNA/AA are included in the facility payment made to the hospital.

(b) Services of a self-employed CRNA/AA or a CRNA/AA who is a member of an independent CRNA/AA group practice is reimbursable directly to the CRNA/AA or CRNA/AA group practice.

(3) Anesthesia time begins when the anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthetic supervision.

(4) The modifier "AA" may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence.

(5) A physician who provides medical direction of a CRNA/AA may submit claim(s) for medical direction of a CRNA/AA as described in paragraph (H)(3) of this rule.

(E) No additional reimbursement will be paid for the physical status of the patient, the age of the patient, body hypothermia, body hyperthermia, emergency conditions, or time of day.

(F) When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a medicaid covered oral surgery procedure for which there is not a surgical code, the anesthesia services must be billed using code 00170 modified by the appropriate anesthesia modifier.

(G) For the reimbursement of anesthesia services the physician must bill the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier as listed in paragraph (D) of this rule, and report the total anesthesia time in minutes.

(1) Except as provided for in paragraph (G)(2) of this rule, when anesthesia services are provided for more than one surgical procedure performed on the same date of service for the same patient, the department will reimburse for only one anesthesia service. Reimbursement will be based on the appropriate anesthesia code and the total anesthesia time reported should be inclusive of the anesthesia time encompassing all of the surgical procedures.

(2) The department will pay for two anesthesia services provided on the same patient on the same date of service on a case-by-case basis only if one or more of the following conditions apply:

(a) The patient was either discharged from the hospital or was released from the recovery/surgical area to the floor or surgical intensive care unit;

(b) The patient had to return to the operating room on an emergency basis;

(c) It was medically necessary for the two procedures to be performed separately and two separate anesthetics were required; or

(d) The patient had anesthesia for a vaginal delivery of a newborn and anesthesia for a tubal ligation procedure meeting the requirements specified in rule 5101:3-21-01 of the Administrative Code performed separately on the same day.

(H) Reimbursement will be made to a provider of physician services for CRNA/AA services under the following conditions:

(1) When the CRNA/AA is employed by a physician, hospital, , or other valid provider of physican services and the claim is for the medicare coinsurance and deductible amounts due for medicare covered CRNA/AA services provided to a patient who is dually eligible for medicare and medicaid, even if separate reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g., hospital-employed CRNA/AA services).

(a) The coinsurance and deductible payments should normally be made through the automatic crossover mechanism.

(b) If the claims for the anesthesia services provided by the CRNA/AA did not get paid through the automatic crossover system, the provider must submit a medicaid crossover claim, in accordance with the crossover billing instructions specified in BIN.1101 except that the CRNA/AA's medicaid legacy number must be submitted as the rendering provider and the employing provider's medicaid legacy number must be submitted as the "pay to" provider.

(c) If the claims for the anesthesia services provided by the CRNA/AA were paid but the claims for the anesthesia services provided by the physician were denied through the automatic crossover system, the provider must submit a medicaid crossover claim, with the physician's medicaid legacy number listed as the rendering provider. If it is a physician group practice the medicaid legacy number for the group practice must be submitted as the "pay to" provider.

(2) When the CRNA is employed by the surgeon. In such cases, the services of the CRNA must be billed on a separate physician claim form from the surgeon and the medicaid legacy number and national provider indentifier number (NPI) of the CRNA must be listed as the rendering provider and the medicaid legacy number and the NPI number of the employing physician or the physician group practice must be listed as the "pay to" provider.

(3) When a CRNA/AA is employed by a physician acting exclusively as an anesthetist as specified in paragraph (C) (1) of this rule or an anesthesiology group practice.

(a) One claim must be submitted when no medical direction or supervision was provided by the physician/anesthesiologist.

(b) Two claims must be submitted when the physician/anesthesiologist meeting the requirement in paragraph (C) (1) of this rule provides medical direction or medical supervision to CRNAs/AAs.

(i) On one claim the physician/anesthesiologist who provided the medical direction would be listed as the rendering provider and the anesthesia code for the anesthesia procedure modified by the appropriate modifier indicating medical direction listed in paragraph (D) (1) of this rule should be billed.

(ii) On the second claim for services provided by the CRNA/AA, the CRNA/AA who provided the service under the medical direction of a physician would be listed as the rendering provider and the physician providing the medical direction would be listed as the "pay to" provider. The appropriate anesthesia code must be modified by "QX" to denote a CRNA/AA under the medical direction of a physician.

(I) Monitored anesthesia care (MAC) is a combination of local anesthesia and certain anxiolytic and analgesic medications. When this type of anesthesia is used, the patient maintains protective reflexes and consciousness except for a brief period of time. Monitored anesthesia care requires the same expertise and work as required in the delivery of general anesthesia. Billing and reimbursement for monitored anesthesia care is the same as for general anesthesia when all of the conditions for reimbursement listed in paragraph (C) of this rule are met. There is no additional reimbursement for monitored anesthesia.

Effective: 11/20/2007
R.C. 119.032 review dates: 08/30/2007 and 11/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 6/3/83, 10/1/83 (Emer), 12/29/83, 1/1/86, 5/9/86, 6/16/88, 1/13/89 (Emer), 4/13/89, 9/1/89, 5/2/94 (Emer), 6/3/94 (Emer), 7/24/94, 3/30/95, 12/31/96 (Emer), 3/22/97, 1/1/00, 5/1/01, 9/1/02