(Medicare Claims Processing Manual)

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.   The physician who medically directs the qualified nonphysician anesthetist would ordinarily report the same time as the qualified nonphysician anesthetist reports for the service.  H. Monitored Anesthesia  Care   Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patients vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure. It also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications (e.g., atropine, demerol, valium) and provision of indicated postoperative anesthesia care.   The A/B MAC pays for reasonable and medically necessary monitored anesthesia care services on the same basis as other anesthesia services. If the physician personally performs the monitored anesthesia care case, payment is made under the fee schedule using  the payment rules for payment at the personally performed rate.  If the physician medically directs four or fewer concurrent cases and monitored anesthesia care represents one or more of these concurrent  cases, payment is made under the fee schedule using the payment rules for payment at the medically directed rate.  Anesthesiologists use the QS modifier to report monitored anesthesia care cases, in addition to reporting the actual anesthesia time and one of the payment modifiers on the claim.    I. Anesthesia Claims  Modifiers   Physicians report the appropriate modifier to denote whether the service meets the requirements for payment at the personally performed rate, medically directed rate, or medically  supervised rate.  AA -  Anesthesia Services performed personally by the  anesthesiologist   AD -  Medical Supervision by a physician; more than 4 concurrent anesthesia  procedures   G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical  procedures   G9 - Monitored anesthesia care for patient who has a history of severe cardio-  pulmonary condition  QK -  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals   QS -  Monitored anesthesia care service   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.   QY -  Medical direction of one qualified nonphysician anesthetist by an anesthesiologist   GC -  These services have been performed by a resident under the direction of a teaching physician.   NOTE:  The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in 100 of this chapter.  One of the payment modifiers must be used in conjunction with the GC  modifier.   The A/B MAC must determine payment for anesthesia in accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate reduction where the anesthesia procedure meets t he requirements for payment at the medically directed rate. They must also be able to determine the number of anesthesia time units from actual anesthesia time reported on the claim. The A/B MAC must multiply allowable units by the anesthesia -specific conv ersion factor used to determine fee schedule payment for the payment  area.   J. Moderate Sedation Services Furnished in Conjunction with and in Support of Procedural Services    Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia. Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care.   Practitioners will report the appropriate CPT and/or HCPCS code that describes the moderate sedation services furnished during a patient encounter, which are furnished in conjunction with and in support of a procedural service, consistent with CPT guidance .    Refer to 50 and 140 of this chapter for information regarding reporting of anesthesia services furnished in conjunction with and in support of procedural services.     K.  Anesthesia for Diagnostic or Therapeutic Nerve Blocks and Services Lower in Intensity than Moderate Sedation  If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the appropriate  CPT code consistent with CPT guidance.  The service must meet the criteria for monitored anesthesia care as described in this section. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologi st or CRNA may report the anesthesia service and the injection or block. However, the anesthesia service must meet the requirements for moderate sedation and if a lower level complexity anesthesia service is provided, then the moderate sedation code should not be  reported.   If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate sedation, such as a local or topical anesthesia, then the moderate sedation code should not be reported and no separate payme nt should be allowed by the A/B MAC.   60 - Payment for Pathology Services (Rev. 2714, Issued: 05- 24-13, Effective: 07 -01-12 Implementation: 06- 25, 13)   A. Payment for Professional Component (PC) Services   Payment may be made under the physician fee schedule for the professional component of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they quali fy as the re -assignee for the physician service.   B. Payment for Technical Component (TC) Services   1. General Rule  Payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings.  Payment is made under the physician fee schedule for TC services furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC).  Payment may be made under the physician fee schedule for the TC of physician pathology ser vices furnished by an independent laboratory, or a hospital if it is acting as an independent laboratory, to non- hospital patients.  The physician fee schedule identifies physician laboratory or physician pathology services that have a TC service.   2. TC Services Furnished by Independent Laboratories to Hospital Inpatients and Outpatients    For services furnished on or after July 1, 2012, an independent laboratory may not bill the A/B MAC (B) (and the A/B MAC (B) may not pay) for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.   For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.  CMS published a final regulation in 1999 that would no longer allow independent laboratories to bill under the physician fee schedule for the TC of physician pathology services.  The implementation of this regulation was delayed by Section 542 of the Benef its and Improvement and Protection Act of 2000 (BIPA).  Section 542 allows the Medicare A/B MAC (B) to continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a cover ed hospital.  This provision is applicable to TC services furnished January 1, 2001 through June 30, 2012.  For this provision, a covered hospital is a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the TC of physician pathology services to fee -for-service Medicare benefi ciaries who were hospital inpatients or outpatients, and submitted claims for payment for the TC to a A/B MAC (B).  The TC could have been submitted separately or combined with the professional component and reported as a combined service.   The term, fee- for-service Medicare beneficiary, means an individual who:    Is entitled to benefits under Part A or enrolled under Part B of title XVIII or both; and   Is not enrolled in any of the following:  A Medicare + Choice plan under Part C of such title; a plan offered by an eligible organization under 1876 of the Social Security Act; a program of all -inclusive care for the elderly under 1894; or a social healt h maintenance organization demonstration project established under Section 4108 of the Omnibus Budget Reconciliation Act of 1987.  In implementing Section 542, the A/B MACs (B) should consider as independent laboratories those entities that it has previously recognized as independent laboratories.   An independent laboratory that has acquired another independent laboratory that had an arrangement of July 22, 1999, with a covered hospital, can bill the TC of physician pathology services for that hospitals inpatients and outpatients under the physician fee schedule.   An independent laboratory that furnishes the TC of physician pathology services to inpatients or outpatients of a hospital that is not a covered hospital may not bill the A/B MAC (B) for the TC of physician pathology services during the time 542 is in eff ect.  If the arrangement between the independent laboratory and the covered hospital limited the provision of TC physician pathology services to certain situations or at particular times, then the independent laboratory can bill the A/B MAC (B) only for these li mited services.   The A/B MAC (B) shall require independent laboratories that had an arrangement, on or prior to July 22, 1999 with a covered hospital, to bill for the technical component of physician pathology services to provide a copy of this agreement, or other document ation substantiating that an arrangement was in effect between the hospital and the independent laboratory as of this date.  The independent laboratory must submit this documentation for each covered hospital that the independent laboratory services.   C. Physician Laboratory and Pathology Services   Physician laboratory and pathology services are limited to:    Surgical pathology services;    Specific cytopathology, hematology and blood banking services that have been identified to require performance by a physician and are listed below;    Clinical consultation services that meet the requirements in subsection 3 below; and    Clinical laboratory interpretation services that meet the requirements and which are specifically listed in subsection 4 below.   1. Surgical Pathology Services   Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare.   Depending upon circumstances and the billing entity, the A/B MACs (B) may pay professional component, technical component or both.  2. Specific Hematology, Cytopathology and Blood Banking Services   Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally excluding hematology.  Examining cervical and vaginal smears are the most common service in cytopathology.  Cervical and vaginal smears do not  require interpretation by a physician unless the results are or appear to be abnormal.  In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality.  This microscopic evaluation ordinarily doe s require performance by a physician.  When medically necessary and when furnished by a physician, it is paid under the fee schedule.   For services furnished prior to January 1, 1999, A/B MACs (B)  pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician.  They must pay under the clinical laboratory fee schedule for pap smears furnished in all other situations.  This  policy also applies to screening pap smears requiring a physician interpretation.  For services furnished on or after January 1, 1999, A/B MACs (B)  allow separate payment for a physicians interpretation of a pap smear to any patient (i.e., hospital or n on-hospital) as long as:  (1) the laboratorys screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.