Medical Policies Online - Policy #: 01.00.08b

Claim Payment Policy

Title:

Preoperative Consultations Performed by Providers in Anesthesia Specialties

Policy #:

01.00.08b

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

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.

Intent

The intent of this policy is to communicate the Company’s coverage and reimbursement position for preoperative consultations performed by providers in anesthesia specialties (ie, anesthesiologists, certified registered nurse anesthetists [CRNAs]).

For information on policies related to this topic, refer to the Cross References Table in this policy.

Description

As used in this policy, providers in anesthesia specialties refers to anesthesiologists and certified registered nurse anesthetists (CRNAs).

The preoperative consultation performed by a provider in an anesthesia specialty involves, at minimum, the taking of an individual's medical and social history, an examination, and medical decision-making, each at a varying level of complexity. A preoperative consultation performed by a provider in an anesthesia specialty is a type of evaluation and management (E&M) service that is provided by an anesthesiologist or CRNA whose opinion or advice is requested by an eligible health care provider regarding the evaluation and/or management of an individual.

Preoperative consultations are frequently performed by providers in anesthesia specialties prior to surgery to determine the surgical candidate's fitness for surgery. Additionally, the preoperative consultation is useful in determining the type of anesthesia (eg, regional, general), anesthetic(s), and dosage(s) that are most medically safe and appropriate for the individual.

Preoperative consultations performed by providers in anesthesia specialties differ in scope and depth from the final preanesthetic assessment and clearance of the surgical candidate, which is performed immediately prior to anesthesia administration and surgery.

Policy

Preoperative consultations performed by providers in anesthesia specialties for new or established patients are covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:

The request is from an eligible health care provider and must be documented in the individual's medical record.
The preoperative consultation must involve a face-to-face service between the consulting provider in an anesthesia specialty and the individual.
- The date of service reported for the preoperative consultation is the date on which the face-to-face service occurs.
The preoperative consultation is performed prior to and is significantly distinct and separate from the final preanesthetic assessment and clearance, which is performed immediately prior to anesthesia administration and surgery.
- Reimbursement for the final preanesthetic assessment is reflected in the base units assigned to the specific anesthesia procedure code and is considered to be integral to the administration of anesthesia.
The provider in an anesthesia specialty prepares a written report of his/her findings, which is both documented in the individual's medical record and provided to the requesting eligible health care provider.
- The medical record documentation for the consultation must be separate and distinct from the final preanesthetic assessment.
Documentation in the medical record must support the level of service reported in accordance with Current Procedural Terminology (CPT�) guidelines.

A preoperative consultation performed by a provider in an anesthesia specialty for a procedure that is subsequently cancelled or discontinued is covered and eligible for reimbursement consideration when all of the above requirements are met.

Preoperative anesthesia consultations performed by certified registered nurse anesthetists (CRNAs) who are employed by a facility or an anesthesiologist/anesthesiology group are not eligible for separate reimbursement from the Company. In general, reimbursement arrangements for covered preoperative anesthesia consultations performed by CRNAs vary based on member and provider contract terms, network rules, and billing conventions that are relevant to the specific services provided.

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

Supporting medical necessity documentation must be maintained in medical records and made available to the Company upon request.

MEDICARE

This policy is consistent with Medicare's coverage of preoperative consultations. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, preoperative consultations performed by providers in anesthesia specialties are covered under the medical benefits of most of the Company’s products.

The Traditional Hospitalization product does not include benefits for professional provider services.

Individual member benefits must be verified.

References

American Society of Anesthesiologists (ASA). Anesthesia and you. [ASA Web site]. Available at: http://www.asahq.org/patientEducation/anesandyou.htm. Accessed June 25, 2008.

Beebe M. Principles of CPT� Coding. 5th ed. Chicago, IL: American Medical Association Press; 2008.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual.Chapter 12: Physicians/nonphysician practitioners. �30.6.10: Consultation services (Codes 99241-99255). [CMS Web site]. Original: 01/01/06. (Revised: 03/07/08). Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 25, 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 July 1, 2008.

Company benefit contracts.

Company provider contracts.

Highmark Medicare Services. Frequently Asked Questions: Consultations (Part B). What are the documentation requirements for consultation services? [Highmark Medicare Services Web site]. Original: 07/19/06. (Revised: 05/19/08). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-consultations.html. Accessed June 25, 2008.

Highmark Medicare Services. Local Coverage Determination (LCD).C-2J: Consultations. [Highmark Medicare Services Web site]. Original: 09/27/93. (Revised: 03/13/07). Available at: http://www.highmarkmedicareservices.com/policy/partb/c1/c2j.html. Accessed June 24, 2008.

Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 23: Evaluation and management. [Highmark Medicare Services Web site]. Original: 04/2008. (Revised: 07/2008). Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/chapter23.pdf. Accessed June 24, 2008.

Highmark Medicare Services. Medicare Report.Consultations: Which code should I bill? [Highmark Medicare Services Web site]. 09/01/04. Available at: http://www.highmarkmedicareservices.com/partb/med-reports/pdf/mr0904.pdf. Accessed June 25, 2008.

Srejic U, Wenker OC: Preoperative anesthesia clinic. The Internet Journal of Health.2002. Volume 2, Number 2. [The Internet Journal of Health Web site]. Available at: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol2n2/preop.xml. Accessed July 2, 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	99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255
ICD Procedure	N/A
ICD Diagnosis	V72.81: Pre-operative cardiovascular examination V72.82: Pre-operative respiratory examination V72.83: Other specified pre-operative examination V72.84: Unspecified pre-operative examination
HCPCS Level II	N/A

Revenue Codes	N/A

Cross References

Cross Reference Policies

00.01.14i:

Reporting and Documentation Requirements for Anesthesia Services

00.01.18b:Reimbursement for Associated Services Performed in Conjunction with Dental Services

01.00.02b:Anesthesia Services for a Cancelled or Discontinued Procedure

Version Effective Date: 04/20/2007