This version of the policy will become effective 04/20/2020. The following criteria have been added to the policy:
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
ANESTHESIA SERVICES PERFORMED BY ANESTHESIA PROVIDERS
Anesthesia services (including Monitored Anesthesia Care [MAC]) performed by an anesthesia provider (i.e., anesthesiologist, certified registered nurse anesthetist [CRNA]), in conjunction with a medically necessary procedure(s) or service(s), are covered and eligible for reimbursement consideration by the Company when the services are reported in accordance with this policy and the appropriate documentation is included on the claim and the individual's medical record.
Medical direction by an anesthesiologist is covered and eligible for reimbursement consideration by the Company when all the following requirements are met:
Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician practitioners. 50 - Payment for anesthesiology services. [CMS Web site]. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed July 24, 2019
Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants.[CMS Web site]. Available at:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/APNPA.html. Accessed May 17, 2018.
Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative Edits.01/2019. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/. Accessed: July, 24, 2019
Optum360. Understanding Modifiers 2018. West Salt Lake City, UT: Optum360; 2017.
American Society of Anesthesiologists (ASA). ASA Annual Meeting Abstracts. Billing for preoperative anesthesia consultations for cancelled surgeries. (ASA Annual Meeting Abstracts Web site.) 08/ 2008. Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=2A371048FC3609B07E0A6462F740D9BC?year=2004&index=15&absnum=1404. Accessed: July, 24, 2019
State of New Jersey. Subchapter 4a. Surgery, Special Procedures, and Anesthesia Services Performed In An Office Setting. [New Jersey State Administrative Code]. https://www.njconsumeraffairs.gov/bme/Documents/Adoption-Surgery-Special-Procedures-and-Anesthesia-Services-Performed-In-An-Office-Setting.pdf. Accessed: 11/08/2019
State of Pennsylvania Department of Health. Hospital Regulations Anesthesia and Respiratory Services, Title 28 § 123.1. [State of Pennsylvania Department of Health]. Available at: https://www.health.pa.gov/topics/Documents/Facilities%20and%20Licensing/028_0123.pdf. Accessed 11/08/2019
99100, 99116, 99135, 99140
99151, 99152, 99153, 99155, 99156, 99157
A MODIFIER FROM THE FOLLOWING LIST IS REQUIRED TO BE REPORTED WHEN REPORTING ANY ANESTHESIA PROCEDURE CODE LISTED IN ATTACHMENT A:
PERFORMANCE VERIFICATION MODIFIERS
Policy: 00.01.52i:Always Bundled Procedure Codes
Policy: 11.15.23i:Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management