130 Mass. Reg. 433.454

Current through Register 1523, June 7, 2024

Section 433.454 - Anesthesia Services

(A)Payment.

(1)Payment Determination. The MassHealth agency pays an anesthesiologist or a Certified Registered Nurse Anesthetist (CRNA) for anesthesia services as described in 101 CMR 316.00: Surgery and Anesthesia, and 130 CMR 433.454. Payment for anesthesia services is determined using a system of base anesthesia units and time anesthesia units.

(2)Base Anesthesia Units. Providers must report the administration of anesthesia on the claim by using the applicable five-digit anesthesia procedure code (00100-01999), and any applicable modifier. The anesthesia procedure code determines the number of base anesthesia units that correspond to the procedure. If a base anesthesia unit is not established for a service, the MassHealth agency pays using time anesthesia units only. When anesthesia is administered for multiple surgery procedures, only the base anesthesia units corresponding to the procedure with the largest number of units is used to determine payment. The number of base anesthesia units does not vary based on the type of anesthesia that is administered.

(3)Time Anesthesia Units.

(a)Payable Anesthesia Time. Payable anesthesia time starts when the anesthesiologist or CRNA begins to prepare the patient for the induction of anesthesia in the operating room or equivalent area. Payable anesthesia time ends when the patient may be safely placed under postoperative supervision.

(b)Reporting Time Anesthesia Units. A provider must report only payable time anesthesia units in the number of units field on the claim. The provider must not include base anesthesia units or units that exceed the criteria set forth in 130 CMR 433.454(A)(3)(a) in the number of units field. Time anesthesia units are measured in minutes. One unit equals one minute.

(4)Personally Performed Anesthesia Services. Anesthesia procedures that are personally performed alone by either an anesthesiologist, or a CRNA not employed by the facility in which the anesthesia services are provided, are payable by MassHealth. For a CRNA, personally performed anesthesia services are those that a CRNA performs alone without medical direction of an anesthesiologist. Payment for personally performed anesthesia services may be claimed by appending the appropriate anesthesia modifier to the anesthesia procedure code. If a CRNA is employed by the facility in which the personally performed anesthesia services are provided, there is no separate payment for the CRNA's services. Refer to subchapter 6 of the Physician Manual for appropriate modifiers.

(5)Medical Direction and Medical Supervision. The MassHealth agency pays for medical direction as described in 101 CMR 316.00: Surgery and Anesthesia and 130 CMR 433.454(C). Refer to Subchapter 6 of the Physician Manual for appropriate modifiers. The MassHealth agency does not pay for medical supervision as further described in 130 CMR 433.454(D).

(B)Services Provided by a Certified Registered Nurse-anesthetist (CRNA).

(1)General. 130 CMR 433.454 applies specifically to physicians and CRNAs. In general however, subject to compliance with state and federal law, the requirements and limitations elsewhere in 130 CMR 433.000 that apply to physicians, also apply to CRNAs, such as service and payment limitations, recordkeeping and reporting requirements, and prior-authorization and other conditions of coverage.

(2)Conditions of Payment. The MassHealth agency pays a CRNA or group practice for CRNA services when

(a) the services are limited to the scope of practice authorized by state law or regulation (including, but not limited to, 244 CMR: Board of Registration in Nursing or of the state licensing agency of another state in which the services are provided);

(b) the CRNA or group practice is not an employee of the hospital or other facility in which the CRNA services were performed, or is not otherwise paid by the hospital or facility for the service;

(c) the CRNA participates in MassHealth pursuant to the requirements of 130 CMR 433.454(B)(3);

(d) the services of the CRNA are provided under the supervision of a physician such that the operating physician or an anesthesiologist is immediately available if needed; and

(e) for an out of state CRNA the requirements of 130 CMR 433.403(C) are met.

(3)CRNA Provider Eligibility. A CRNA may enroll in MassHealth as a provider. Any CRNA applying to participate as a provider in MassHealth must submit documentation, satisfactory to the MassHealth agency, that he or she

(a) is licensed to practice as a CRNA by the Massachusetts Board of Registration in Nursing or by the licensing agency of another state in which the CRNA services are provided; and

(b) is a member of a group practice or is in a solo private practice.

(C)Medical Direction of Anesthesia Services. The MassHealth agency pays an anesthesiologist for medical direction of a CRNA as follows. The term medical direction is used in 130 CMR 433.454(C) for payment purposes only.

(1) Medical direction of anesthesia services occurs when an anesthesiologist is involved in no more than four concurrent anesthesia procedures and provides all of the following seven services to a patient:

(a) perform a pre-anesthetic examination and evaluation;

(b) prescribe the anesthesia plan;

(c) personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence;

(d) ensure that any procedures in the certified registered nurse anesthesia plan that he or she does not perform, are performed by a qualified anesthetist;

(e) monitor the course of anesthesia administration at frequent intervals;

(f) remain physically present and available for immediate diagnosis and treatment of emergencies; and

(g) provide the indicated post-anesthesia care.

(2) If one or more of the above services in 130 CMR 433.454(C)(1)(a) through (1)(g) are not performed by the anesthesiologist, the service is not considered medical direction.

(3) Ordinarily, the anesthesiologist should not furnish additional services to other patients while concurrently directing the administration of anesthesia. The anesthesiologist can, however, provide any of the following services to other patients while medically directing the administration of anesthesia without affecting the anesthesiologist's ability to provide medical direction.

(a) addressing an emergency of short duration in the immediate area;

(b) administering an epidural or caudal anesthetic to ease labor pain;

(c) periodic rather than continuous monitoring of an obstetrical patient;

(d) receiving patients entering the operating suite for the next surgery;

(e) checking on or discharging patients from the post anesthesia care unit; and

(f) coordinating scheduling matters.

(4) Payment for medical direction of a CRNA may be claimed by appending the appropriate anesthesia modifier to the anesthesia procedure code.

(a) If an anesthesiologist provides medical direction of a CRNA who participates in MassHealth in accordance with 130 CMR 433.454(B)(3), and is not employed by the facility in which the anesthesia services are performed, the anesthesiologist receives 50% of the fee and the CNRA receives 50% of the fee.

(b) If an anesthesiologist provides medical direction of a CRNA employed by a facility in which the anesthesia service is performed, the anesthesiologist receives 50% of the fee, but no separate payment is made for the CRNA's services.

(c) Anesthesiologists and CRNAs should refer to subchapter 6 of the Physician Manual for appropriate modifiers.

(D)Medical Supervision of Anesthesia Services. The MassHealth agency does not pay a physician for medical supervision of a CRNA. The term medical supervision is used in this section for payment purposes only.

(1) Medical supervision of anesthesia services occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures and when the anesthesiologist provides some, but not all of the seven required services under medical direction in 130 CMR 433.454(C)(1)(a) through (1)(g).

(2) Medical supervision also occurs when the seven required services under medical direction in 130 CMR 433.454(C)(1)(a) through (1)(g) are not performed by an anesthesiologist. This might occur in cases when the anesthesiologist:

(a) left the immediate area of the operating suite for more than a short duration;

(b) devotes extensive time to an emergency case; or

(c) was otherwise not available to respond to the immediate needs of the surgical patients.

(E)Acupuncture as an Anesthetic. The MassHealth agency pays for acupuncture as a substitute for conventional surgical anesthesia (see130 CMR 433.440).