Intent

The intent of this policy is to communicate the Company's coverage and reimbursement position for anesthesia services for a cancelled or discontinued procedure performed by a provider in an anesthesia specialty (anesthesiologist and/or certified registered nurse anesthetist [CRNA]). For information on policies related to this topic, refer to the Cross References Table in this policy.

Description

There are times or situations when it is necessary to cancel or discontinue a procedure after the anesthesiologist and/or certified registered nurse anesthetist (CRNA) has rendered services associated with that procedure. These services may include, but are not limited to, the following: Preanesthetic assessment of the patient Prescription of an anesthetic agent(s) Administration of an anesthetic agent(s) Postoperative management of the patient Evaluation and management (E&M) service codes represent the evaluation of an individual's medical condition and the medical management of that condition by a provider. Requirements for the reporting of these services are outlined in the American Medical Association's (AMA) Current Procedural Terminology (CPT) Manual, which is published annually. As used in this policy, anesthesia provider refers only to providers in anesthesia specialties (ie, anesthesiologist, CRNA).

Policy

The Company covers and considers for reimbursement anesthesia services performed by an anesthesia provider in association with or prior to the cancellation or discontinuation of a covered procedure and reported as follows: If the procedure is cancelled due to the assessment of the the patient's condition during the anesthesia provider's presurgical/preanesthetic evaluation and prior to induction of regional or general anesthesia, report the following: An evaluation and management (E&M) code that reflects the type and level of service performed The Company applies the applicable Current Procedural Terminology (CPT) E&M service reporting guidelines to all E&M (eg, consultation E&M) codes. A description of and an indication that the procedure was cancelled or discontinued and either V64.1 or V64.3 as a secondary diagnosis to identify the surgical procedure that was cancelled or discontinued If the procedure is cancelled following the anesthesia provider's presurgical/preanesthetic assessment and the patient's preparation for surgery, and before induction of regional or general anesthesia, report CPT code 01999 (unlisted anesthesia procedure[s]): A description of and an indication that the procedure was cancelled or discontinued and either V64.1 or V64.3 as a secondary diagnosis to identify the surgical procedure that was cancelled or discontinued The reporting of base units in association with CPT code 01999 is not required as the Company applies three base units in calculating reimbursement. If the procedure is cancelled or discontinued after general or regional anesthesia induction has occurred, report the following: The appropriate American Society of Anesthesiologists (ASA) code corresponding to the surgical procedure plus the time expended, in minutes, providing the anesthesia services The reporting of base units in association with the ASA code is not required as the Company applies the ASA recommended base units for the ASA code in calculating the reimbursement. If reimbursement for the ASA code is considered by the Company at a flat rate, time is not applied and should not be reported. Individual provider fee schedules apply. ADDITIONAL BILLING REQUIREMENTS Providers must report the following: The primary diagnosis(es), and, as a secondary diagnosis, either V64.1 or V64.3 to identify that the procedure was cancelled or discontinued A description of the procedure and an indication that the procedure was cancelled or discontinued As applicable, the E&M code that most accurately represents the service performed when an E&M code is reported The Company applies CPT E&M service reporting guidelines to all E&M (eg, consultation E&M) codes. The E&M guidelines in the edition of the CPT Manual that is current on the date that the E&M service (eg, consultation) was performed are applied. Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. REQUIRED DOCUMENTATION The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports. The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

Guidelines

Preoperative consultations performed by providers in anesthesia specialties differ in scope and depth from the preanesthetic assessment of the surgical candidate. The preanesthetic assessment is routinely performed prior to anesthesia administration and surgery or prior to a nonsurgical procedure for which the services of an anesthesia provider is required. Refer to the policy addressing preoperative consultations performed by providers in anesthesia specialties for additional information and requirements. Providers in anesthesia specialties should not report Modifier 74 (discontinued outpatient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia) with anesthesia procedure codes (00100-01999). Modifier 74 does not identify a code as a cancelled or discontinued anesthesia service or an anesthesia service that was performed in association with a cancelled or discontinued procedure. Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. MEDICARE Although Medicare covers anesthesia services for a cancelled or discontinued procedure, claims received for anesthesia services for a cancelled or discontinued procedure for the Company's Medicare Advantage members are processed in accordance with this policy. The Company's payment methodology may differ from Medicare.

References

American Society of Anesthesiologists. 2008 Relative Value Guide™: A Guide for Anesthesia Values. Park Ridge, IL: ASA Press; 2007. American Society of Anesthesiologists (ASA). ASA Annual Meeting Abstracts. Billing for preoperative anesthesia consultations for cancelled surgeries. (ASA Annual Meeting Abstracts Web site.) Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=2A371048FC3609B07E0A6462F740D9BC?year=2004&index=15&absnum=1404. Accessed August 22, 2008. American Society of Anesthesiologists (ASA). Patient education Web site: Scope of practice. [ASA Web site]. Available at: http://www.asahq.org/patientEducation.htm#scope.Accessed August 22, 2008. American Society of Anesthesiologists (ASA). Practice advisory for preanesthesia evaluation. A report by the ASA Task Force on preanesthesia evaluation. Original: February 2002. (Revised: 10/15/03). [ASA Web site]. Available at: http://www.asahq.org/publicationsAndServices/preeval.pdf. Accessed August 25, 2008. Beebe M, Dalton JA, Espronceda M, Evans DD, Glenn RL, eds. Current Procedural Terminology: CPT® 2008. Appendix D. Chicago, IL: American Medical Association; 2008. Beebe M. Principles of CPT®. 5th ed. Chicago, IL: American Medical Association; 2008. Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual for Part B Medicare Carriers. Chapter II, Version 13.3: Anesthsia services. [CMS Web site]. 12/07/07. Available at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage (zip folder document: CHAP2final083107.doc). Accessed August 22, 2008. Centers for Medicare & Medicaid Services (CMS). The Carriers Manual. Part 3, Chapter XVI: Fee schedule for physicians’ services. §15018. Payment conditions for anesthesiology services. [CMS Web site].November 2002. Available at: http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021921&intNumPerPage=10. (zip folder document : b3_15000_to_15903.doc). Accessed August 22, 2008.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System Code Number(s) and Narrative(s) CPT 01999 ICD Procedure N/A ICD Diagnosis SECONDARY DIAGNOSIS CODES V64.1: Surgical or other procedure not carried out because of contraindication V64.3: Procedure not carried out for other reasons HCPCS Level II N/A Revenue Codes N/A

Cross References

Cross Reference Policies

00.01.14h:Reporting and Documentation Requirements for Anesthesia Services 01.00.08b:Preoperative Consultations Performed by Providers in Anesthesia Specialties

Version Effective Date: 12/16/2008

The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2010 AmeriHealth, Inc. All Rights Reserved.  Current Procedural Terminology ©2010 American Medical Association. All Rights Reserved.