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.