Reimbursement Rate Changes for Anesthesiologists, CRNAs and/or AAs Effective for Dates of Service on or After Nov. 1, 2017

Transcription

1 Reimbursement Rate Changes for Anesthesiologists, CRNAs and/or AAs Effective for Dates of Service on or After Nov. 1, 2017 Information posted Oct. 25, 2017 Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details. The Health and Human Services Commission (HHSC) has reviewed and evaluated the reimbursement methodology and payment rates for Texas Medicaid anesthesiology supervision as directed by the General Appropriations Act, S.B. 1, 85th Legislature, Regular Session, 2017 [Article II, HHSC, Rider 223], and presented the proposed changes at the public rate hearing held on Sept. 20, Effective for dates of service on or after Nov. 1, 2017, rate changes will be implemented based on specific modifiers, conversion factors and set rates billed by the following: Chart 1: Anesthesia modifier combinations submitted by anesthesia providers Provider Anesthesiologist** Anesthesiologist supervising one CRNA/AA Anesthesiologist supervising two, three, or four CRNA/AAs Anesthesiologist supervising five or more CRNA/AAs Supervised CRNA or AA CRNA directed by a physician** Modifiers AA plus U1 QY plus U1 or QY plus U2 QK plus U1 or QK plus U2 AD plus U1 or AD plus U2 QX plus U2 QZ plus U1 **Important: Medical services solely performed by an anesthesiologist (modifier AA plus U1) will continue to receive 100 percent of the calculated rate while a CRNA (modifier QZ plus U1) who is supervised by a physician will continue to receive 92 percent of the calculated rate. Two adjustments are being implemented: 1. Conversion factors and set rates for anesthesia services for children and adults will be increased. 2. Reimbursement percentages for supervised services will be decreased. Note: The dental anesthesia conversion factor for adults and children is not changing. Conversion Factor and Set Rate Increases The conversion factors and set rates for anesthesia services will be increased for supervised services. The non-obstetrics and obstetrics conversion factors for anesthesia services will be combined into one conversion factor for children and one for adults.

2 Chart 2: Conversion factors for anesthesia services will be as follows: Type Current Conversion Factor On/After Nov. 1, 2017 Children Non-obstetrics $19.83 Obstetrics $23.22 Adults Non-obstetrics $18.42 Obstetrics $19.58 $25.60 $24.32 Dental (All ages) $ $ (No change) Chart 3: Set rates for anesthesia services will be as follows: Procedure Code Current Set Rate On/After Nov. 1, Children - $ Adults - $ Children - $ Adults - $ Children - $ Adults - $ Children - $ Adults - $ Children - $32.98 Adults - $27.80 Children - $32.98 Adults - $ Manually Priced Manually Priced Reimbursement Percentage Decreases for Supervised Services The reimbursement percentage paid to the anesthesiologist and to the CRNA or AA for supervised anesthesia services will be decreased to 50 percent of the calculated physician/anesthesiologist rate. Chart 4: Reimbursement percentage for supervised services will be as follows: Provider Current Percent Reduction Percent Reduction On/After Nov. 1, 2017 Anesthesiologist supervising a CRNA or AA CRNA or AA 75 percent of the calculated physician/anesthesiologist rate 92 percent of the calculated physician/anesthesiologist rate 50 percent of the calculated physician/anesthesiologist rate 50 percent of the calculated physician/anesthesiologist rate The following tables contain the rate changes that will be applied for the conversion factors, set rates, and reimbursement percentage by medical service: Reimbursement to Anesthesiologist Table 1 Reimbursement to Certified Registered Nurse Anesthetist and Anesthesiologist Assistant Table 2

3 Anesthesia Set Rate Procedure Codes Table 3 For more information about anesthesia services rate changes, providers can refer to the article titled, Reimbursement Change for Anesthesiologists Directing Certified Registered Nurse Anesthetists and Anesthesiologist Assistants, which was posted on the TMHP website at on Oct , and providers can refer to the proposed reimbursement rates on the HHSC rate analysis web page at legacy-hhsc.hhsc.state.tx.us/rad/rate-packets.shtml. For more information, call the TMHP Contact Center at

4 Table 1: Reimbursement to Anesthesiologist Anesthesia Modifiers Current Modifier Combination Adjustment Modifier Combination Adjustment - Effective Current Five Conversion Factors Three Conversion Factors Effective 1/1/2017 AA plus U1 QY plus U1 QY plus U2 QK plus U1 QK plus U2 AD plus U1 AD plus U2 100 percent of calculated rate 75 percent of calculated rate 100 percent of calculated rate 50 percent of calculated rate Children: Non-Obstetrics: $19.83; Obstetrics: $23.22; Adults: Non-Obstetrics: $18.42; Obstetrics: $19.58; Children: $25.60; Adults: $24.32; (no change) QX plus U2 Description of Anesthesia Modifiers: AA plus U1 = Anesthesiologist personally performing the anesthesia service QY plus U1 and QY plus U2 = Anesthesiologist is medically directing one CRNA, AA, or other qualified professional AD plus U1 and AD plus U2 = Anesthesiologist for medical supervision for more than four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals. Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrence requiring five or more concurrent procedures. QX plus U2 = CRNA, AA, or other qualified professional who provided services under the medical direction of an anesthesiologist.

5 Table 2: Reimbursement to Certified Registered Nurse Anesthetist and Anesthesiologist Assistant Anesthesia Modifiers Current Modifier Combination Adjustment Modifier Combination Adjustment - Effective Current Five Conversion Factors Three Conversion Factors Effective QY plus U1 QY plus U2 QK plus U1 QK plus U2 AD plus U1 AD plus U2 QX plus U2 92 percent of calculated rate 50 percent of calculated rate Children: Non-Obstetrics: $19.83; Obstetrics: $23.22; Adults: Non-Obstetrics: $18.42; Obstetrics: $19.58; Children: $25.60; Adults: $24.32; (no change) QZ plus U1 92 percent of calculated rate 92 percent of calculated rate Description of Anesthesia Modifiers: QY plus U1 and QY plus U2 = Anesthesiologist is medically directing one CRNA, AA, or other qualified professional. QK plus U1 and QK plus U2 = Anesthesiologist is medically directing two, three, or four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals. AD plus U1 and AD plus U2 = Anesthesiologist for medical supervision for more than four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals. Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrence requiring five or more concurrent procedures. QX plus U2 = CRNA, AA, or other qualified professional who provided services under the medical direction of an anesthesiologist. QZ plus U1 = CRNA has personally performed the anesthesia services while directed by a physician.

6 Table 3: Set Rates for Anesthesia Services TOS* Procedure Code Age Range Facility (F) Current Medicaid Fee Current Adjusted Medicaid Fee Medicaid Fee Effective Independent Anesthesiologist (AA-U1) (See Note 1) Anesthesiologist Supervising a CRNA/AA (See Note 2) CRNA/AA when supervised by an anesthesiologist (See Note 2) CRNA Supervised by a Physician (Billing with QZ-U1) (See Note 3) F $ $ $ $ $ $ $ F $ $ $ $ $ $ $ F $ $ $ $ $ $ $ F $ $ $ $ $ $ $ F $33.65 $32.98 $32.98 $32.98 Not applicable Not applicable $ F $28.37 $27.80 $27.80 $27.80 Not applicable Not applicable $ F Manually Priced Manually Priced Manually Priced Manually Priced Manually Priced Manually Priced Manually Priced *Type of Service (TOS): 1 = Medical Services, 7 = Anesthesia **Modifiers: AA-U1 = Anesthesiologist personally performs the anesthesia service, QZ-U1 = CRNA personally performs the anesthesia services while directed by a physician. Note 1: Medical service solely performed by an anesthesiologist will be reimbursed 100 percent of the calculated payment rate (AA-U1) Note 2: Supervised services will be reimbursed 50 percent of the calculated payment to a supervising anesthesiologist, and supervised CRNA and/or AA. Note 3: A CRNA supervised by a physician (QZ-U1) will be reimbursed 92 percent of the calculated payment rate.