(Medicare Claims Processing Manual)

Example 1:   Physician personally performs the anesthesia case   Base Units plus time units -  4+4=8  Total units multiplied by the anesthesia conversion factor times .80  8 x $17= ($136.00 -  (deductible*) x .80 = $108.80  Payment amount times 115 percent for the CAH method II payment.  $108.80 x 1.15 = $125.12 (Payment amount)  $125.12 x .10 = $12.51 (HPSA bonus payment)  *Assume the Part B deductible has already been met for the calendar year   Formula 2:  Calculate the payment for the physicians medical direction service when the physician directs two concurrent cases involving CRNAs. The medical direction allowance is 50% of the allowance for the anesthesia service personally performed by the physician.   HCPCS = xxxxx  Modifier = QK  Base Units = 4  Time Units 60/15=4  Sum of base units plus time units = 8  Locality specific anesthesia conversion factor = $17(varies by localities)  Coinsurance = 20 %   (Allowed amount adjusted for applicable deductions and coinsurance and to reflect payment percentage for medical direction).   Example 2:   Physician medically directs two concurrent cases involving CRNAs Base units plus time -  4+4=8  Total units multiplied by the anesthesia conversion factor times. 50 equal allowed amount minus any remaining deductible  8 x $17 = $136 x .50 = $68.00 - (deductible*) = $68.00  Allowed amount Times 80 percent times 1.15  $68.00 x .80 = $54.40 x 1.15 = 62.56 (Payment amount)  $62.56 x .10 = $6.26 (HPSA bonus payment)  *Assume the deductible has already been met for the calendar year.   NOTE:   For specific guidance on payment for Anesthesia and Teaching Services please review the following sections:   -   Payment for Anesthesiology Services Pub.100- 04, Chapter 12, Section 50   - Teaching Physician Services Pub.100- 04, Chapter 12, Section 100.1.2 (4) Anesthesia.   250.3.3 - Anesthesia and CRNA Services in a Critical Access Hospital (CAH)  (Rev. 616, Issued: 07- 22-05, Effective: 10 -01-02, Implementation: 01- 03-06)  250.3.3.1 - Payment for CRNA Pass -Through Services  (Rev.4295, Issued: 05- 03-19, Effective: 08 -27-19, Implementation: 08- 27-19)  CAHs are eligible to receive CRNA pass -through payments (pass -through exemption) for both inpatient and outpatient services if they meet criteria discussed at 42 CFR  412.113(c) of the regulations. CRNA pass -through payments and the Method II election for outpatient CAH services are applied as described below. Note that for CAHs that have a CRNA pass -through exemption, all CRNA services provided to CAH swing- bed patients must be included on the CAH swing- bed bill. (See MCPM, Ch. 3, 60 and 100.2 for more information)   If a CAH meets the criteria for a pass -through exemption and is interested in selecting Method II for its physicians and/or other practitioners, it can choose Method II for all outpatient professionals except the CRNA, and still retain the approved CRNA pa ss-through exemption for both inpatient and outpatient CRNA professional services.   Alternatively, a CAH, with an approved pass -through exemption, can choose to give up its pass -through exemption for both inpatient and outpatient CRNA professional services in order to include its CRNA outpatient professional services under Method II. By c hoosing to include the CRNA under Method II for outpatient services, the CAH loses its CRNA pass -through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services. All A/B MAC (A) payments for CRNA services are subject to cost settlement.   Provider Billing Requirements for CRNA Pass -Through   TOBs = 11X and 18X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing- bed) and outpatient   Deductible and coinsurance apply.   Provider Billing Requirements for CRNA Pass -Through   TOB = 85X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Anesthesia HCPCS codes and for any HCPCS codes for services the CRNA is legally authorized to perform in the state in which the services are furnished.   The appropriate HCPCS should be included when required for the applicable TOB and or revenue code.   Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing -bed) and outpatient   Deductible and coinsurance apply.    Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass - through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.                         .      250.3.3.2 - Payment for Anesthesia Services by a CRNA (Method II CAH only)  (Rev. 4157, Issued: 11- 02-18, Effective: 04 -01-19, Implementation: 04- 01-19)  Provider Billing Requirements for Method II CRNA -  Gave up Pass -Through Exemption (or never had exemption)   TOB = 85X   Revenue Code = 037X for CRNA technical service   Revenue Code = 0964 for CRNA professional service   HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished   Reimbursement -  For dates of service on or after July 1, 2007  Revenue Code 037X for CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964 for CRNA professional service = Based on 100 percent of the allowed amount when not medically directed or 50 percent of the allowed amount when medically directed.   Providers bill a QZ modifier for non- medically directed CRNA services. Deductible and coinsurance apply.   How to calculate payment for anesthesia claims based on the formula -  For dates of service on or after July 1, 2007  Identify anesthesia claims by HCPCS code range from 00100 through 01999 Non-medically directed CRNA   (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15  Medically directed CRNA   (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsurance) times 1.15   Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass -through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.  Reimbursement -  For dates of service prior to July 1, 2007   Revenue Code 037X for CRNA technical service = cost reimbursement   Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of allowed amount (Use Anesthesia formula) for outpatient CRNA professional services.   Providers a QZ modifier for non -medically directed CRNA services. Deductible and coinsurance apply.   How to calculate payment for anesthesia claims based on the formula -  For dates of service prior to July 1, 2007  Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific anesthesia conversion factor (file name below).   The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.   If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.   Base Formula   Number of minutes divided by 15, plus the base units = Sum of base units and time  Sum of base units and time times the conversion factor = allowed amount   Source  Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS   Conversion Factor = File -  MU00.@BF12390.MPFS.CYXX.ANES.V1023      250.4 - CAH Outpatient Services Part B Deductible and Coinsurance  (Rev. 1070, Issued: 09- 29-06, Effective: 01 -01-07, Implementation: 01- 02-07)  Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amounts unless waived based on statute.   For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual.   Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost -sharing - no coinsurance, deductible, copayment, or any other cost -sharing.    250.5 - Medicare Payment for Ambulance Services Furnished by Certain CAHs  (Rev. 4390, Issued: 10- 07-19, Effective: 10 -01-19, Implementation: 10- 07-19)  Medically necessary ambulance services furnished for dates of service on or after December 21, 2000 and prior to January 1, 2004, by a CAH or by an entity that is owned and operated by the CAH are paid based on 100 percent of the reasonable costs if the 35 mile rule for reasonable cost -based payment is met.   For dates of service on or after January 1, 2004, medically necessary ambulance services furnished by a CAH or by an entity that is owned and operated by the CAH are paid based on 101 percent of the reasonable costs if the 35 mile rule for reasonable cost -based payment is met.   For dates of service on or after December 21, 2000 and prior to October 1, 2011, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located withi n a 35 mile drive of the CAH or the entity.   For dates of service on or after October 1, 2011 and prior to October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH.  Additionally, if there is no provider or supplier of ambulance services located within a 35 mile drive of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH -owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   For dates of service on or after October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH, e xcluding ambulance providers or suppliers that are not legally authorized to furnish ambulance services to transport individuals either to or from the CAH. Additionally, if there is no provider or supplier of ambulance services located within a 35 mile dri ve of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH- owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   Section 205 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 exempts certain CAHs from the current Medicare ambulance cost per trip payment limit as well as from the ambulance fee schedule. Section 205(a) of BIPA states: