Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.21-010 - Physician Manual-Anesthesia Services

Current through Register Vol. 49, No. 6, June, 2024
Field Name and Number
Instructions for Completion
SEX
Not required.
c.
RESERVED
Reserved for NUCC use.
d.
INSURANCE PLAN NAME OR PROGRAM NAME
Name of the insurance company.
10.
IS PATIENT'S CONDITION RELATED TO:
a.
EMPLOYMENT?
(Current or Previous)
Check YES or NO.
b.
AUTO ACCIDENT?
Required when an auto accident is related to the
							 services. Check YES or NO.
PLACE (State)
If 10b is YES, the two-letter postal abbreviation for
							 the state in which the automobile accident took place.
c.
OTHER ACCIDENT?
Required when an accident other than automobile is
							 related to the services. Check YES or NO.
d.
CLAIM CODES
The "Claim Codes" identify additional information
							 about the beneficiary's condition or the claim. When applicable, use the Claim
							 Code to report appropriate claim codes as designated by the NUCC. When required
							 to provide the subset of Condition Codes, enter the condition code in this
							 field. The subset of approved Condition Codes is found at
www.nucc.org
under Code Sets.
11.
INSURED'S POLICY GROUP OR FECA NUMBER
Not required when Medicaid is the only
							 payer.
a.
INSURED'S DATE OF BIRTH
Not required.
SEX
Not required.
b.
OTHER CLAIM ID NUMBER
Not required.
c.
INSURANCE PLAN NAME OR PROGRAM NAME
Not required.
d.
IS THERE ANOTHER HEALTH BENEFIT
							 PLAN?
When private or other insurance may or will cover any
							 of the services, check YES and complete items 9, 9a and 9d. Only one box can be
							 marked.
12.
PATIENT'S OR AUTHORIZED PERSON'S
							 SIGNATURE
Enter "Signature on File," "SOF" or legal
							 signature.
13.
INSURED'S OR AUTHORIZED PERSON'S
							 SIGNATURE
Enter "Signature on File," "SOF" or legal
							 signature.
14.
DATE OF CURRENT:
ILLNESS (First symptom) OR INJURY (Accident) OR
							 PREGNANCY (LMP)
Required when services furnished are related to an
							 accident, whether the accident is recent or in the past. Date of the
							 accident.
Enter the qualifier to the right of the vertical
							 dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last
							 Menstrual Period.
15.
OTHER DATE
Enter another date related to the beneficiary's
							 condition or treatment. Enter the qualifier between the left-hand set of
							 vertical, dotted lines.
The "Other Date" identifies additional date
							 information about the beneficiary's condition or treatment. Use
							 qualifiers:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-Ray
471 Prescription
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date)
444 First Visit or Consultation
16.
DATES PATIENT UNABLE TO WORK IN CURRENT
							 OCCUPATION
Not required.
17.
NAME OF REFERRING PROVIDER OR OTHER
							 SOURCE
Primary Care Physician (PCP) referral is required for
							 most Physician/Independent Lab/CRNA/Radiation Therapy Center services provided
							 by non-PCPs. Enter the referring physician's name and title.
17a.
(blank)
Not required.
17b.
NPI
Enter NPI of the referring physician.
18.
HOSPITALIZATION DATES RELATED TO CURRENT
							 SERVICES
When the serving/billing provider's services charged
							 on this claim are related to a beneficiary's or participant's inpatient
							 hospitalization, enter the individual's admission and discharge dates. Format:
							 MM/DD/YY.
19.
ADDITIONAL CLAIM INFORMATION
Identifies additional information about the
							 beneficiary's condition or the claim. Enter the appropriate qualifiers
							 describing the identifier. See
www.nucc.org
for qualifiers.
20.
OUTSIDE LAB?
Not required.
$ CHARGES
Not required.
21.
DIAGNOSIS OR NATURE OF ILLNESS OR
							 INJURY
Enter the applicable ICD indicator to identify which
							 version of ICD codes is being reported.
Use "9" for ICD-9-CM
Use "0" for ICD-10-CM.
Enter the indicator between the vertical, dotted
							 lines in the upper right-hand portion of the field.
Diagnosis code for the primary medical condition for
							 which services are being billed. Use the appropriate version of the
							 International Classification of Diseases. List no more than 12 ICD diagnosis
							 codes. Relate lines A-L to the lines of service in 24E by the letter of the
							 line. Use the highest level of specificity.
22.
RESUBMISSION CODE
Reserved for future use.
ORIGINAL REF. NO.
Any data or other information listed in this field
							 does not/will not adjust, void or otherwise modify any previous payment or
							 denial of a claim. Claim payment adjustments, voids and refunds must follow
							 previously established processes in policy.
23.
PRIOR AUTHORIZATION NUMBER
The prior authorization or benefit extension control
							 number if applicable.
24
A.
DATE(S) OF SERVICE
The "from" and "to" dates of service for each billed
							 service. Format: MM/DD/YY.
1. On a single claim detail (one charge on one line),
							 bill only for services provided within a single calendar month.
2. Providers may bill on the same claim detail for
							 two or more sequential dates of service within the same calendar month when the
							 provider furnished equal amounts of the service on each day of the date
							 sequence.
B.
PLACE OF SERVICE
Two-digit national standard place of service code.
							 See Section 292.200 for codes.
C.
EMG
Check "Yes" or leave blank if "No." EMG identifies if
							 the service was an emergency.
D.
PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS
One CPT or HCPCS procedure code for each
							 detail.
MODIFIER
Modifier(s) if applicable.
For anesthesia, when billed with modifier(s) P1, P2,
							 P3, P4, or P5, hours and minutes must be entered in the shaded portion of that
							 detail in field 24D.
E.
DIAGNOSIS POINTER
Enter the diagnosis code reference letter (pointer)
							 as shown in Item Number 21 to relate to the date of service and the procedures
							 performed to the primary diagnosis. When multiple services are performed, the
							 primary reference letter for each service should be listed first; other
							 applicable services should follow. The reference letter(s) should be A-L or
							 multiple letters as applicable. The "Diagnosis Pointer" is the line letter from
							 Item Number 21 that relates to the reason the service(s) was
							 performed.
F.
$ CHARGES
The full charge for the service(s) totaled in the
							 detail. This charge must be the usual charge to any client, patient, or other
							 beneficiary of the provider's services.
G.
DAYS OR UNITS
For paper claims, including Anesthesia on paper
							 claims, enter the units (in whole numbers) of service(s) provided during the
							 period indicated in Field 24A of the detail.
For electronic claims submission, for Anesthesia
							 services, enter total minutes.
H.
EPSDT/Family Plan
Enter E if the services resulted from a Child Health
							 Services (EPSDT) screening/referral.
I.
ID QUAL
Not required.
J.
RENDERING PROVIDER ID #
Enter the 9-digit Arkansas Medicaid provider ID
							 number of the individual who furnished the services billed for in the detail
							 or
NPI
Enter NPI of the individual who furnished the
							 services billed for in the detail.
25.
FEDERAL TAX I.D. NUMBER
Not required. This information is carried in the
							 provider's Medicaid file. If it changes, please contact Provider
							 Enrollment.
26.
PATIENT'S ACCOUNT NO.
Optional entry that may be used for accounting
							 purposes; use up to 16 numeric or alphabetic characters. This number appears on
							 the Remittance Advice as "MRN."
27.
ACCEPT ASSIGNMENT?
Not required. Assignment is automatically accepted by
							 the provider when billing Medicaid.
28.
TOTAL CHARGE
Total of Column 24F-the sum all charges on the
							 claim.
29.
AMOUNT PAID
Enter the total of payments previously received on
							 this claim. Do not include amounts previously paid by Medicaid. * Do
not
include in this total the automatically deducted Medicaid or
							 ARKids First-B co-payments.
30.
RESERVED
Reserved for NUCC use.
31.
SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES
							 OR CREDENTIALS
The provider or designated authorized individual must
							 sign and date the claim certifying that the services were personally rendered
							 by the provider or under the provider's direction. "Provider's signature" is
							 defined as the provider's actual signature, a rubber stamp of the provider's
							 signature, an automated signature, a typewritten signature, or the signature of
							 an individual authorized by the provider rendering the service. The name of a
							 clinic or group is not acceptable.
32.
SERVICE FACILITY LOCATION INFORMATION
If other than home or office, enter the name and
							 street, city, state, and zip code of the facility where services were
							 performed.
a.
(blank)
Not required.
b.
(blank)
Not required.
33.
BILLING PROVIDER INFO & PH #
Billing provider's name and complete address.
Telephone number is requested but not
							 required.
a.
(blank)
Enter NPI of the billing provider or
b.
(blank)
Enter the 9-digit Arkansas Medicaid provider ID
							 number of the billing provider.
292.440
Anesthesia Services 10-1-21
Anesthesia procedure codes (
00100
through
01999
) must be billed in anesthesia time.
Anesthesia modifiers
P1
through
P5
listed under Anesthesia Guidelines in the CPT must be used. When appropriate,
				anesthesia procedure codes that have a base of four (4) or fewer are eligible
				to be billed with a second modifier,
"22
,
"
referencing surgical field avoidance.
Reimbursement for use and administration of local or topical
				anesthesia is included in the primary surgeon's reimbursement for the surgery
				that requires such anesthesia. No modifiers or time may be billed with these
				procedures.
A. Electronic Claims
For electronic claims for Anesthesia services (procedure codes
				00100 through 01999), total minutes should be billed in the units field.
B. Paper Claims
If paper billing is required, enter the procedure code, time,
				and units as shown in Section 292.447. Enter again the number of units (each
				fifteen (15) minutes of anesthesia equals one (1) time unit) in Field 24G. (See
				cutaway section of a completed claim in Section 292.447.)
C. The following CPT procedure codes require
			 attachments or documentation.
Procedure Code
Description
Documentation Required
00800
Anesthesia for procedures on lower anterior abdominal
						  wall; not otherwise specified
Operative Report
00840
Anesthesia for intraperitoneal procedures in lower
						  abdomen, including laparoscopy; not otherwise specified
Operative Report
00840
Modifier UI
Anesthesia for Abdominal Hysterectomy
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
00840
Modifier U2
Anesthesia for Laparoscopic
						  Hysterectomy
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
00840
Modifier U3
Anesthesia for Supra-cervical Hysterectomy, any
						  method
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
00846
Radical hysterectomy
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
00848
Pelvic exenteration
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
00922
Anesthesia for procedures on male genitalia (including
						  open urethral procedures); seminal vessels
Operative Report
00940
Anesthesia for vaginal procedures (including biopsy of
						  labia, vagina, cervix or endometrium); not otherwise specified
Operative Report
00944
Vaginal hysterectomy
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
01962
Anesthesia for urgent hysterectomy following
						  delivery
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
01963
Anesthesia for cesarean hysterectomy without labor
						  analgesia/anesthesia care
Operative Report
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
View or print form DMS-2606 and instructions for
						  completion.
01965
Anesthesia for incomplete or missed abortion
						  procedure
Procedure requires the following ICD diagnosis code
						  (View ICD Codes.). Any other diagnosis billed with this procedure code requires
						  paper billing and documentation to justify the procedure
01966
Anesthesia for induced abortions. Use for billing
						  anesthesia services for all elective, induced abortions, including abortions
						  performed for rape or incest.
Operative Report
Certification Statement for Abortion (DMS-2698). (See
						  Sections 251.220, 261.000, 261.100, 261.200, and 261.260 of this manual.) View
						  or print form DMS-2698 and instructions for completion.
01999
Unlisted anesthesia procedure(s)
Procedure Report
***Other documentation may be requested upon
				review.
D.
			 Anesthesiologist/anesthetists may bill procedure code
00170
for
			 any inpatient or outpatient dental surgery using place of service code
			 "
11
," "
21
," "
22
", or "
24
,"
			 as appropriate. This code does not require Prior Approval for anesthesia
			 claims.
E. A maximum of seventeen
			 (17) units of anesthesia are allowed for a vaginal delivery or Cesarean
			 Section. Refer to Anesthesia Guidelines of the CPT book for procedure codes
			 related to vaginal or Cesarean Section deliveries. Only one (1) anesthesia
			 service is billable for Arkansas Medicaid as the anesthesia for a delivery. The
			 anesthesia service ultimately provided should contain all charges for the
			 anesthesia. No add-on codes are payable.