Anesthesia claims and reimbursement

Professional anesthesia claims must be submitted using the CPT anesthesia codes. If applicable, the claim must also be billed with the appropriate physical-status modifier and, if needed, other optional modifiers.

An anesthesia claim must specify who provided the service. In cases where an anesthesiologist provides a portion of the service and a nonphysician anesthetist performs the remainder, the claim must identify exactly which services each type of provider provided. This distinction may be made by the use of modifiers.

 

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Calculating anesthesia reimbursement rates

TRICARE calculates anesthesia reimbursement rates using the number of time units, the Medicare Relative Value Units (RVU) and the anesthesia conversion factor.

The following formula is used to calculate the TRICARE anesthesia reimbursement: (time units + RVUs) × conversion factor

Base unit: TRICARE anesthesia reimbursement is determined by calculating a base unit, derived from the Medicare Anesthesia Relative Value Guide, plus an amount for each unit of time the anesthesiologist is in attendance (in the beneficiary’s presence).

A base unit includes reimbursement for:

  • Preoperative examination of the beneficiary
  • Administration of fluids and/or blood products incident to the anesthesia care
  • Interpretation of noninvasive monitoring (e.g., electrocardiogram, temperature, blood pressure, oximetry, capnography and mass spectrometry)
  • Determination of the required dosage/method of anesthesia
  • Induction of anesthesia
  • Follow-up care for possible postoperative effects of anesthesia on the beneficiary

Services not included in the base unit include placement of arterial, central venous and pulmonary artery catheters and the use of trans-esophageal echocardiography. When multiple surgeries are performed, only the RVUs for the primary surgical procedure are considered, while the time units should include the entire surgical session.

Note: This does not apply to continuous epidural analgesia.

Time unit: Time units are measured in 15-minute increments, and any fraction of a unit is considered a whole unit. Anesthesia time starts when the specialist begins to prepare the beneficiary for anesthesia in the operating room or in an equivalent area. It ends when the anesthesiologist is no longer in personal attendance and the beneficiary may be safely placed under post-anesthesia supervision. Providers must indicate the number of time units in column 24G of the CMS-1500 form.

Conversion factor: the sum of the time units and RVUs is multiplied by a conversion factor. Conversion factors differ between physician and nonphysician providers and vary by state, based on local wage indexes.

For more specific information on anesthesia reimbursement calculation and methodologies, refer to the TRICARE Reimbursement Manual