CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 3747 Date: April 14, 2017 Change Request 10001 SUBJECT: Payment for Moderate Sedation Services I. SUMMARY OF CHANGES: This CR clarifies existing Manual language to bring the Manual in line with current payment policy for moderate sedation and anesthesia services. EFFECTIVE DATE: January 1, 2017 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: May 15, 2017 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

2 II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 12/50/Payment for Anesthesiology Services R 12 Nonphysician Anesthetists R 12 or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician Anesthetists R 12 Fee Schedule Payment for Qualified Nonphysician Anesthetists R 12 Factors Used for Qualified Nonphysician Anesthetists R 12 Time and Calculation of Anesthesia Time Units R 12 Modifiers R 12 Billing Instructions R 12 Anesthesiologist and Qualified Nonphysician Anesthetist Work Together R 12 Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure R 12 for medical or Surgical Services Furnished by CRNAs R 12 for Anesthesia Services Furnished by a Teaching CRNA III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract.

3 CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-04 Transmittal: 3747 Date: April 14, 2017 Change Request: 10001 SUBJECT: Payment for Moderate Sedation Services EFFECTIVE DATE: January 1, 2017 *Unless otherwise specified, the effective date is the date of service.

4 IMPLEMENTATION DATE: May 15, 2017 I. GENERAL INFORMATION A. Background: The purpose of this CR is to clarify existing Manual language to bring the Manual in line with current payment policy for moderate sedation and anesthesia services. B. Policy: This revision represents a change in policy for payment of moderate sedation services furnished in conjunction with and in support of certain procedural services. II. BUSINESS REQUIREMENTS table "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF Contractors shall note the changes to Pub. 100-04, Medicare Claims Processing Manual , Chapter 12, Sections 50 and 140. X X Contractors need not search their files to either retract payment for claims already paid or to retroactively pay claims.

5 However, contractors shall adjust claims brought to their attention. X X I. PROVIDER EDUCATION table Number Requirement Responsibility A/B MAC DME MAC CEDI A B HHH MLN Article: A provider education article related to this instruction will be available at shortly after the CR is released. You will receive notification of the article release via the established "MLN Matters" listserv. Contractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within 5 business days after receipt of the notification from CMS announcing the availability of the article. In addition, the provider education article shall be included in the contractor's next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly.

6 X X IV. SUPPORTING INFORMATION Section A: Recommendations and supporting information associated with listed requirements: N/A "Should" denotes a recommendation. X-Ref Requirement Number Recommendations or other supporting information: Section B: All other recommendations and supporting information: N/A V. CONTACTS Pre-Implementation Contact(s): Jamie Hermansen, 410-786-2064 or , Gail Addis, 410-786-4522 or Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR). VI. FUNDING Section A: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer.

7 If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENTS: 0 50 - Payment for Anesthesiology Services (Rev. 3747; Issued: 04-14-17; Effective: 01-01-17; Implementation: 05-15-17) A. General Payment Rule The fee schedule amount for physician anesthesia services furnished is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure is communicated to the A/B MACs by means of the HCPCS file released annually. CMS releases the conversion factor annually. The base units and conversion factor are available on the CMS website at: B.

8 Payment at Personally Performed Rate The A/B MAC must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time if: The physician personally performed the entire anesthesia service alone; The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in 100; The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case that meets the requirements for payment at the medically directed rate. The physician meets the teaching physician criteria in ; The physician is continuously involved in a single case involving a student nurse anesthetist; If the physician is involved with a single case with a qualified nonphysician anesthetist (a certified registered nurse anesthetist (CRNA) or an anesthesiologist s assistant)), A/B MACs may pay the physician service and the qualified nonphysician anesthetist service in accordance with the requirements for payment at the medically directed rate; Or The physician and the CRNA (or anesthesiologist s assistant) are involved in one anesthesia case and the services of each are found to be medically necessary.

9 Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the AA modifier and the CRNA reports the QZ modifier. C. Payment at the Medically Directed Rate The A/B MAC determines payment at the medically directed rate for the physician on the basis of 50 percent of the allowance for the service performed by the physician alone. Payment will be made at the medically directed rate if the physician medically directs qualified individuals ( all of whom could be CRNAs, anesthesiologists assistants, interns, residents, or combinations of these individuals) in two, three, or four concurrent cases and the physician performs the following activities. Performs a pre-anesthetic examination and evaluation; Prescribes the anesthesia plan; Personally participates in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence; Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; Monitors the course of anesthesia administration at frequent intervals; Remains physically present and available for immediate diagnosis and treatment of emergencies; and Provides indicated post-anesthesia care.

10 The physician must document in the medical record that he or she performed the pre-anesthetic examination and evaluation. Physicians must also document that they provided indicated post-anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedures in the anesthesia plan, including induction and emergence, where indicated. NOTE: Concurrency refers to to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist medically directs three concurrent procedures, two of which involve non-Medicare patients and the remaining a Medicare patient, this represents three concurrent cases. The requirements for payment at the medically directed rate also apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologist s assistant, intern or resident).