(Medicare Claims Processing Manual)

Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  For those procedures with an indicator of 0, the limitation on liability provisions described in Chapter 30 apply to assigned claims.  Therefore, carriers include the appropriate limitation of liability language from Chapter 21.  For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity. Where payment may not be made for a co - or team surgeon, deny the claim   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.13  Where payment may not be made for a two surgeons, deny the claim.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  Also see limitation of liability remittance notice Remittance Advice Remark Code Alert M27 and use when appropriate.   40.9 - Procedures Billed With  Two or More Surgical Modifiers (Rev. 1, 10- 01-03) B3-4829 A/B MACs (B) may receive claims for surgical procedures with more than one surgical modifier.  For example, since the global fee concept applies to all major surgeries, A/B MACs (B) may receive a claim for surgical care only (modifier - 54) for a bilateral surgery (modifier -50).  They may also receive a claim for multiple surgeries requiring the use of an assistant surgeon.  Following is a list of possible combinations of surgical modifiers.  (NOTE:  A/B MACs (B) must price all claims for surgical teams by report.)   Bilateral surgery (-50) and multiple surgery (- 51).   Bilateral surgery (-50) and surgical care only (-54).  Bilateral surgery (-50) and postoperative care only ("55).  Bilateral surgery (-50) and two surgeons (-62).  Bilateral surgery (- 50) and surgical team (- 66).   Bilateral surgery (-50) and assistant surgeon (-80).  Bilateral surgery (-50), two surgeons (-62), and surgical care only (- 54).   Bilateral surgery (- 50), team surgery (-66), and surgical care only (- 54).   Multiple surgery (-51) and surgical care only (-54).  Multiple surgery (-51) and postoperative care only ("55).  Multiple surgery (-51) and two surgeons (-62).  Multiple surgery (- 51) and surgical team (- 66).   Multiple surgery (-51) and assistant surgeon (-80).  Multiple surgery (-51), two surgeons (-62), and surgical care only (- 54).   Multiple surgery (- 51), team surgery (-66), and surgical care only (- 54).   Two surgeons (-62) and surgical care only (- 54).   Two surgeons (-62) and postoperative care only (55).  Surgical team ( -66) and surgical care only (- 54).   Surgical team ( -66) and postoperative care only (55). Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier -62) or team surgeons (modifier - 66) is appropriate.  If A/B MACs (B) receive a bill for an assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.  50 - Payment for Anesthesiology  Services  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17)   A. General Payment  Rule   The fee schedule amount for physician anesthesia services furnished is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure i s communicated to the A/B MACs by means of the HCPCS file released annually.  CMS releases the conversion factor annually.  The base units and conversion factor are available on the CMS website at: https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html.     B. Payment at Personally Performed  Rate   The A/B MAC must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time 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 as defined in 100;   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 that meets the requirement s for payment at the medically directed rate. The physician meets the teaching physician criteria in 100.1.4;    The physician is continuously involved in a single case involving a student nurse  anesthetist;   If the physician is  involved with  a single  case with a qualified nonphysician anesthetist (a certified registered nurse anesthetist ( CRNA)  or an anesthesiologists assistant)),  A/B  MACs  may pay the physician service and  the qualified nonphysician anesthetist  service in accordance with the requirements for payment at the medically directed rate;    Or   The physician and the CRNA (or anesthesiologists assistant) 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. The physician reports the AA  modifier and the CRNA reports the QZ modifier.   C. Payment at the Medically Directed  Rate   The A/B MAC determines payment at the medically directed rate for the physician on the basis of 50 percent of the allowance for the service performed by the physician alone. Payment will be made at the medically directed rate if the physician medically directs qualified individuals (all of whom could be CRNAs, anesthesiologists assistants, interns, residents, or combinations of these 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, if applicable, induction and emergence;    Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified  individual;    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.   The physician must document in the medical record that he or she performed the pre -anesthetic examination and evaluation.  Physicians must also document that they provided indicated post -anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedu res in the anesthesia plan, including induction and emergence, where  indicated.  NOTE:  C oncurrency refers to to the maximum number of procedures that the physician is medically directing within the context of a single procedure and  whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist medically directs three concurrent procedures, two of which involve non -Medicare patients and the remaining a Medicare patient, this represents three concurrent cases.   The requirements for payment at the medically directed rate also apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologists assistant, intern or  resident).   The requirements for payment at the medically directed rate do not apply to a single resident case that is concurrent to another anesthesia case paid at the medically directed rate or to two concurrent anesthesia cases involving residents.   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 ano ther member of the group furnishes the other component parts of the anesthesia  service.  However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.   A physician who is concurrently furnishing services that meet the requirements for payment at the medically directed rate cannot ordinarily be involved in furnishing additional services to other patients. However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, periodic (rather than continuous) monitoring of an obstetrical patient, receiving patients entering the operating suite for the next surgery, checking or discharging patients in the recovery room, or handling scheduling matters, do not substantially diminish the scope of control exercised by the physician and do not constitute a separate service for the purpose of determining whether the requirements for payment at the  medically directed rate are met.    However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physicians services to the surgical patients would not meet the requirements for payment at the medically directed rate. A/B MACs may not make payment under the fee  schedule.    D. Payment at Medically Supervised  Rate   The A/B MAC 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.  E. Billing and Payment for Multiple Anesthesia  Procedures   Physicians bill for the anesthesia services associated with multiple bilateral surgeries by reporting the anesthesia procedure with the highest base unit value with the multiple procedure modifier - 51. They report the total time for all procedures in the l ine item with the highest base unit value.   If the same anesthesia CPT code applies to two or more of the surgical procedures, billers enter the anesthesia code with the - 51 modifier and the number of surgeries to which the modified CPT code  applies.   Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral 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.  See 40.6-40.7 for billing and claims processing instructions for multiple and bilateral surgeries.   F. Payment for Medical and Surgical Services Furnished in Addition to Anesthesia  Procedure   Payment may be made under the fee schedule for specific medical and surgical services furnished by the anesthesiologist as long as these services are reasonable and medically necessary or provided that other rebundling provisions (see 30 and Chapter 23) do not preclude separate payment. These services may be furnished in conjunction with the anesthesia procedure to the patient or may be furnished as single services, e.g., during the day of or the day before the anesthesia service. These services include the insertion of a Swan Ganz catheter, the insertion of central venous pressure lines, emergency intubation, and critical care visits.   G. Anesthesia Time and Calculation of Anesthesia Time  Units   Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.  Actual anesthesia time in minutes is reported on the claim. For anesthesia services furnished, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place. The A/B MAC does not recognize time units for CPT code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration).  For purposes of this section, anesthesia practitioner means:   a physician who performs the anesthesia service alone,   a CRNA who is furnishing services that do not meet the requirements for payment at the medically directed rate,   a qualified nonphysician anesthetist who is furnishing services that meet the requirements for payment at the medically directed rate.