2.0 APPLICABILITY
The policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
4.0 POLICY
4.1 Procedure
codes. Claims are to be billed using the Current Procedural Terminology,
4th Edition (CPT-4) anesthesia codes.
4.2 Payment.
Payment is calculated by multiplying the applicable conversion factor
by the appropriate number of base units plus time units for each
code.
4.2.1 There are two conversion factors--one
for physicians and one for non-physicians, and the conversion factors
are adjusted by wage indexes for each locality. The locality-specific
conversion factors are adjusted in the same manner applied to CHAMPUS
Maximum Allowable Charges (CMACs). That is, the current contractor-maintained
conversion factors are compared to the Medicare locality-specific
conversion factors, and the conversion factors are reduced a maximum
of 15% a year or to the Medicare level.
4.2.2 Base units
for each procedure are derived from the Medicare Anesthesia Relative
Value Guide. Time units are 15 minutes, and any fraction of a unit
is considered a whole unit. Time units will be as submitted on the claim.
4.3 Files provided to contractors.
Each year the contractors will receive a file which contains the
conversion factors (two per locality) along with the number of base
units per CPT-4 code.
4.4 Identification
of provider. Since payment rates distinguish between physicians
and non-physicians, each anesthesia claim must identify who provided
the anesthesia. In those cases where part of the anesthesia service
is provided by an anesthesiologist and the remainder by a nonphysician
anesthetist, the claim(s) must identify exactly the services provided
by each type of provider, so that the appropriate payment level
can be used.
4.5 Anesthesia administered by
operating surgeon. Administration of general anesthesia by the operating surgeon
is not covered. If the surgeon bills a single charge which includes
both the surgery and the anesthesia, a breakdown of the charge should
be obtained and the anesthesia services denied. When a breakdown
of charges is not available, payment will be based on the allowable
charge for the surgery alone.
4.6 Total
payment. Generally the total amount allowed or anesthesia provided
by an anesthesiologist and a nonphysician anesthetist cannot exceed
what would have been allowed had the anesthesia been provided only
by an anesthesiologist. In no case can it exceed that amount if
the nonphysician anesthetist is an anesthesiologist assistant. If
the nonphysician anesthetist is a certified registered nurse anesthetist,
the total allowed amount can exceed that amount only if unusual
circumstances warrant additional payment and those circumstances
are documented in the medical record.