N.J. Admin. Code § 10:54-4.19

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:54-4.19 - Anesthesiology

(a) Anesthesiologists shall be reimbursed for anesthesia services provided to a Medicaid/NJ FamilyCare program beneficiary for the total of the anesthesia base units (ABUs) plus anesthesia time.

(b) The use of a HCPCS procedure code which has anesthesia base units (ABUs) assigned requires that the "AA" modifier be utilized to allow the claim to be processed to adjudication. The physician shall enter the HCPCS procedure code and the "AA" modifier in FIELD 24D on the claim form.

(c) An "AA" modifier shall be used for either:

1. Services performed by an anesthesiologist; or

2. Services performed by a Certified Nurse Anesthetist (CRNA) personally and directly supervised by an anesthesiologist.

(d) "Anesthesia time (A.T.)" means that period which includes:

1. Those professional activities of the anesthesiologist directly related to the pre-operative preparation of the patient in the operating room or pre-induction room preceding the proposed surgery;

2. Introduction of the anesthetic agent;

3. Continuous supervision during the surgery; and

4. Continuous supervision during the immediate post-operative period until release of the patient in a satisfactory physiological state to a competent recovery room staff.

(e) Anesthesia time shall be reported in 15 minute quantities (one unit equals 15 minutes). The anesthesiologist shall convert the anesthesia time into units and the number of unit(s) shall be entered in FIELD 24F on the claim form. Do not enter the time (hours and/or minutes) in the "units" field. The anesthesia time (hours and/or minutes) shall be entered at the bottom of "FIELD 24D-Description".

(f) Reimbursement for anesthesia shall be determined by the following, unless otherwise noted:

1. The anesthesia base units assigned to the HCPCS procedure code will be automatically added to the number of the units entered by the anesthesiologist in FIELD 24F at the time the claim is processed. The total of ABUs plus the number of units in FIELD 24F will be multiplied by the Medicaid fee per unit for the total Medicaid allowance. (Do not add anesthesia base unit(s) to the unit(s) of service reported in FIELD 24F.)

2. When multiple surgical procedures are rendered during the same operative session, only the one procedure code with the highest anesthesia base unit value shall be used in calculating and billing the anesthesia allowance.

Example: For multiple surgery reimbursement calculation, if multiple surgeries are performed in one operative session within the time span of the surgery (or anesthesia time (A.T.) listed as 2 hours and 45 minutes), the reimbursement should be calculated as follows: (B.U.V.) = 7 plus (A.T.) of 11 units = 18 units multiplied by dollar amount for specialist or non-specialist = Total Anesthesia Reimbursement.

3. A list of procedure codes which do not require the AA modifier when the physician's professional services are rendered by the anesthesiologist is located under anesthesia in N.J.A.C. 10:54-9.4, HCPCS.

4. The New Jersey Medicaid Management Information system (NJMMIS) does not recognize the CPT-4 anesthesia codes (00100-01999) as valid on the procedure code file. Therefore, claims submitted using these anesthesia codes, including automatic crossover claims from the Medicare Carrier will be suspended or denied. If a new CMS 1500 claim form with an Explanation of Medicare Benefits (EOMB) notice attached is submitted, claims will be processed.

(g) Reimbursement for anesthesia services provided by an Advanced Practice Nurse specializing in anesthesia shall be made, provided:

1. He or she is employed by a physician who is a specialist in anesthesia who is:

i. An approved provider in the New Jersey Medicaid/NJ FamilyCare program; and

ii. The person who submits the claim for services rendered; and

2. The APN/Anesthesia's services were performed under the personal direction of the employer anesthesiologist throughout the period of anesthesia. (See N.J.A.C. 10:54-2.2(a) and (b) for rules related to personal direction of the APN/Anesthesia, as applicable).

(h) The New Jersey Medicaid/NJ FamilyCare program shall not reimburse an APN/Anesthesia directly, nor shall it reimburse charges submitted by an anesthesiologist for services rendered by an APN/Anesthesia who is not in his or her employ, but is in the employ of a health care facility.

N.J. Admin. Code § 10:54-4.19

Recodified from N.J.A.C. 10:54-4.18 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:54-4.19, Radiology; general, recodified to N.J.A.C. 10:54-4.20.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (a), substituted "beneficiary" for "recipient" preceding "for the total".
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (a), inserted "/NJ FamilyCare program"; in (f)4, substituted "CMS" for "HCFA"; in the introductory paragraph of (g), substituted "an Advanced Practice Nurse specializing in anesthesia" for "Certified Registered Nurse Anesthetists (CRNA)"; in (g)1i and (h), inserted "/NJ FamilyCare"; in (g)2, substituted "APN/Anesthesia's" for "CRNA's" and "APN/Anesthesia" for "CRNA"; and in (h), substituted "an APN/Anesthesia" for "a CRNA" twice.