La. Admin. Code tit. 40 § I-5117

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5117 - Anesthesia

A. General. The total anesthesia allowance is calculated by adding the basic value units, time value units, plus any applicable modifier unit values and/or unusual qualifying circumstances units and multiplying the sum by a dollar amount allowed per unit.

1. Basic Units. A basic unit is listed for most procedures. The allowable basic units are shown in the following schedule. When multiple surgical procedures are performed during the same period of anesthesia, only the greater basic unit allowance of the various surgical procedures will be used as the base. The basic value for each procedure includes pre- and post-operative visits, administration of fluids and/or blood incident to the anesthesia care and interpretation of noninvasive monitoring (EKG, temperature, blood pressure, oximetry capnography and mass spectrometry). When multiple surgical procedures are performed during the same period of anesthesia, only the highest base unit allowance of the various surgical procedures will be used.

2. Time Units. Time begins when the anesthesiologist begins to prepare the patient anesthesia care in the operating room or in a equivalent area. Time ends when anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. The anesthesia time units will be calculated in 15-minute intervals, or portions thereof, equaling one time unit. In each instance, five minutes or greater is considered a significant portion of a time unit. No additional time units are allowed for recovery room time and monitoring.

3.

a. Modifier Units. Physical status modifiers are represented by the letter "P" followed by a single digit defined below.

i.	Healthy Patient	0
ii.	Patient with mild systemic disease	0
iii.	Patient with severe systemic disease	1
iv.	Patient with severe systemic disease threat to life	2
v.	A moribund patient who is not expected to survive without the operation	3
vi.	A declared brain-dead patient whose organs are being removed for donor purposes	0
The above six levels are consistent with the American Society of Anesthesiologist (ASA) ranking of patient physical status.
Example: 00100-P1

4. Qualifying circumstances warrant additional value due to unusual events. The following list of CPT-4 codes and the corresponding anesthesia unit values may be listed if appropriate. More than one code may be necessary. The unit value listed is added to the existing anesthesia base units.

CPT-4		Units
99100	Anesthesia for patient of extreme age, under one year and over 70	1
99116	Anesthesia complicated by utilization of total body hypothermia	5
99135	Anesthesia complicated by utilization of controlled hypotension	5
99140	Anesthesia complicated by emergency conditions (specify)	2
(An emergency is defined as existing when delay in treatment of a patient would lead to a significant increase in the threat to life or body part.)

5. Any procedure around the head, neck or shoulder girdle requiring field avoidance or any other procedure requiring a position other than supine or lithotomy, has a basic value of 5.0 units regardless of any lesser value assigned to such procedure. A medical report must be attached to document the special unit.

6. Unlisted Service or Procedure. When an unlisted service or procedure is provided, the value should be substantiated "by report." These services are shown in this schedule as "BR."

7. Procedures Listed without Specified Unit Values. "BR" in the value column indicates that the value of this service is to be determined "by report" because the service is too unusual or variable to be assigned a unit value.

8. Monitored Anesthesia Care. Monitored anesthesia care occurs when the attending physician requests that an anesthesiologist be present during a procedure. This may be to insure compliance with accepted procedures of the facility. Monitored Anesthesia Care includes pre-anesthesia exam and evaluation of the patient. The anesthesiologist must participate or provide medical direction for the plan of care. The anesthesiologist, resident, or nurse anesthetist must be in continuous physical presence and provide diagnosis and treatment of emergencies. This will also include noninvasive monitoring of cardiocirculatory and respiratory systems with administration of oxygen and/or intravenous administration of medications. Reimbursement will be the same as if general anesthesia had been administered (time units + base units).

9. More Than One Anesthesiologist. When it is necessary to have a second anesthesiologist, the necessity should be substantiated by report "BR." It is recommended that the second anesthesiologist receive 5 base units + time units (calculation of total anesthesia value).

10. Amount Payable

a. The amount payable for anesthesia services will be the lesser of the actual charge or $50 times the total allowed units as determined by this schedule and the above guidance.

b. The total anesthesia allowance is calculated by adding the basic unit value, the number of time units, plus any applicable modifier and/or unusual circumstance units and multiplying the sum by the $50 allowed per unit.

c. When non-anesthetic procedures are performed by anesthesiologist, they should use the surgical or medical code and fee established for that code. Anesthesia units and conversion factors are to be used only when the primary purpose of the service is to anesthetize the patient so that the surgical procedure can be performed.

d. Trigger point injection is considered one procedure and is reimbursed as such regardless of the number of injection sites.

B. Reimbursement Guidelines for Anesthesia Services. Anesthesia services may be billed for any one of the three following circumstances.

1. An anesthesiologist provides total and individual anesthesia service.

2. An anesthesiologist directs a CRNA.

3. Anesthesia provided by a CRNA working independent of an anesthesiologist's supervision is covered under all the following conditions.

a. The service falls within the CRNA's scope of practice and scope of license as defined by law.

b. The service is reasonable and medically necessary.

c. The service is supervised by a licensed health care provider who has prescriptive authority.

d. The service is provided under one of the following conditions:

i. in accordance with the clinical privileges individually granted by the hospital or other health care organization;

ii. the doctor performing the procedure requiring the service specifically requests the service of a CRNA;

iii. the patient requiring the service specifically requests the service of a CRNA;

iv. the services are provided by a CRNA in connection with a medical emergency; or

v. no anesthesiologist is on staff or an anesthesiologist is unable to provide the service.

e. Payment for covered anesthesia services provided by a CRNA will be limited to the lesser of the actual charge or 80 percent of the medical reimbursement guideline total anesthesia value. Use Modifier -QZ.

f. Where a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed CRNA, the payment amount for the service of each is 50 percent of the allowance otherwise recognized had the service been furnished by the anesthesiologist alone.

i. Use Modifier -QX if medical direction by physician.

ii. Use Modifier -QY if medical direction for one CRNA by anesthesiologist.

iii. Reimbursement shall not be made to either the anesthesiologist or the CRNA until the insurer has received and reviewed the bill and the anesthesia report from both providers.

iv. Reimbursement shall never exceed 100 percent of the maximum amount an anesthesiologist would have been allowed under the Medical Fee Schedule Allowance had the anesthesiologist or physician alone performed the services.

v. Medical supervision, as opposed to medical direction, occurs when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures. No additional reimbursement shall be made for general supervisory services rendered by the anesthesiologist or other physician.

La. Admin. Code tit. 40, § I-5117

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 47606 (5/1/2021).

The following Sections apply to all the schedules mentioned in the beginning of Chapter 51: §§5119, 5121, 5123, 5145, 5147, 5149, and 5153.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.