Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993) Consultation fees in accordance with the Consultation Services Unit Anaesthesia Guidelines to Billing 2012

 

Services involving administration of anaesthesia are reported by the use of the Doctors Guide to Billing codes plus modifier codes defined under Anaesthesia Modifiers.

 

 

 

 

 

 

The Evaluation / Management consultation services are in addition to the above services.

 

 

EVALUATION / MANAGEMENT CONSULTATION SERVICES:

 

These include:

 

Pre-operative assessment (codes 0151-0153). This is face-to-face time spent with the patient, assessing prior medical and surgical history, medication and allergic history, prior anaesthetics, examination and discussion of anaesthetic techniques and risk, ordering of appropriate investigations and ordering of any pre-operative medication. This assessment may also be done in the theatre admission area, and whilst this is not ideal, it is understood that due to late admissions on the day of surgery and other explanations it is not always possible to see the patient in the ward.

 

If the pre-operative assessment is not followed by an operation, it would be regarded as a Consultation and items 0173-0175 for In-hospital Consultations and items 0190-0192 for Consultations in own rooms, will apply (see modifier 0024).

 

Unscheduled emergency consultation service, without travel (code 0146) and with travel (code 0147). Only one of these items may be used as an add-on to the consultation service (codes 0151-0153. 0173-0175) if, the procedure is unbooked/unscheduled (i.e. not booked on a scheduled slate, or booked as an add-on to an elective slate after the theatre slates have been finalised by the theatre booking secretary) and surgery is of an emergency diagnosis (ie. failure to treat within a restricted time-period of 24hrs may well result in loss of life, limb or significant complications).

 

Post-operative assessments (code 0109). Anaesthesiology does not have a global fee component and therefore if cardio-respiratory, pain or any other assessment or intervention is necessary, this code will apply.

 

Consultation services provided at own consultation rooms (including pain clinic consultations) done prior to the anaesthetic to assess fitness for anaesthesia and to improve physical status prior to an anaesthetic, codes 0190-0193, will apply.

 

 

REPORTING OF ANAESTHESIA SERVICES:

 

All anaesthesia values are determined by adding a Basic Unit Value. which is related to the complexity of the service, plus Time Units, plus Modifying Units (if any).

 

Basic value or base unit: the basic value, also referred to as the base unit or relative value, is listed for anaesthetic management of most surgical procedures. This includes the value of all usual anaesthesia services except for the time actually spent in anaesthesia care and any modifiers.

 

The basic value units have two components:

 

One component reflects all usual services included in the anaesthesia service. Usual services include:

administration of fluids and/or blood products incident al to the procedure and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, oximetry and capnography).

 

The second component reflects the relative work or cost of the specific anaesthesia service. Cost in this context refers to the medical practitioner's expertise/training/ risk. For example, the basic value for the anaesthesia service related to a closed reduction of a radius fracture might be 3,00 anaesthetic units, as it has a relatively low level of work or cost. The basic value for an anaesthesia service associated with an intrathoracic coronary artery bypass graft procedure might be 15,00 anaesthetic units. reflecting a high level of work or cost.

 

Two exceptions to using the basic value are listed, namely:

 

A minimum basic value of 4,00 anaesthetic units are allowed for all procedures of the head, neck or shoulder girdle, requiring field avoidance (code 0034).

 

In addition, any procedure performed in any position other than lithotomy or supine has a minimum basic value of 4,00 anaesthetic units (item 0032).

 

If the anaesthesia code associated with the surgical procedure carries a basic value greater than four. the higher basic value is reported.

 

Excluded from the Basic Unit Value are:

Unusual forms of monitoring e.g. placement of intra-arterial, central venous and pulmonary artery catheters;

Use of trans-oesophageal echocardiography (TEE);

Use of special equipment.

 

 

TIME (CODE 0023):

 

Anaesthetic time is the actual time spent providing the anaesthesia service. Time begins as the anaesthesiologist prepares the patient for anaesthesia care in the operating room or in an equivalent area. Time ends when the personal attendance of the anaesthesiologist is no longer required and the patient can be safely placed in postanaesthesia recovery under the supervision of nursing or other trained personnel. Should a second patient receive an anaesthetic before the discharge of the first patient from the recovery unit, then the anaesthetic time for the first patient shall cease.

 

Time is reported in units based on defined time increments. For the first hour of anaesthesia 2,00 anaesthetic units are allocated to each 15 minute period or part thereof, thereafter 3,00 anaesthetic units are allocated per each 15 minute period or part thereof. On some anaesthesia services, time is not reported additionally. A '+T' is designated after the base unit for procedures requiring time reported separately. Do not list time separately for procedures without this designation.

 

 

RAND CONVERSION FACTOR (RCF):

 

Anaesthesia charges must be calculated by means of a conversion factor since the charges are not based on fixed amounts. The conversion factor is the Rand value associated with each unit of anaesthesia. The Rand conversion factor is multiplied by the total number of anaesthesia units (basic, time and modifiers. if applicable) for a given anaesthesia service, to arrive at the total charges for the anaesthesia service.

 

Standard formula: The total anaesthesia units for a given anaesthesia service are determined by using the total units multiplied by the Rand Conversion Factor (RCF). The total charge for a specific anaesthesia service is calculated by means of the following formula:

 

Basic value + Time units + Modifying units = Anaesthetic units

 

Additional Procedure units x RCF +Consult units x RCF + Anaesthetic units x RCF =Total fee for the procedure

 

 

MONITORED (STAND-BY) ANAESTHESIA:

 

Monitored anaesthesia care is defined as instances where an anaesthesiologist has been requested to provide specific services to a patient undergoing a planned procedure. The patient receives either local anaesthesia or no anaesthesia. However, the anaesthesiologist is required to provide pre-operative assessment, to remain in attendance during the procedure to monitor the patient and to administer additional anaesthetics should it be required and to provide post-operative services as required.

 

Monitored care. as described above, is any other anaesthesia procedure. The procedure should be assigned the applicable anaesthesia code with time and modifying units being added as for general anaesthesia.

 

When an anaesthesiologist is requested by the attending medical practitioner to be present in the operating room to monitor vital signs and manage the patient on an anaesthesia level, even though the actual surgery is being done under local anaesthesia, calculations will be the same as if general anaesthesia had been administered (time + base value).

 

Stand-by anaesthesia is generally accepted without motivating documents for the following:

Vaginal deliveries;

Subdural haematomas;

Vascular imaging and interventional procedures e.g. angioplasty, stents, embolectomy and filters;

lnterventional radiology;

Patients with physical status ASA 3 or ASA 4;

Insertion of a cardiac pacemaker, cardiac catheterizations and coronary angiograms and coronary stents; and

Cataract extraction and/or lens implant.

 

 

MORE THAN ONE ANAESTHESIOLOGIST- MODIFIER 0029:

 

When it is necessary to have a second anaesthesiologist it is recommended that the remuneration for the second anaesthesiologist shall be calculated at the same rate for the first hour and thereafter at 80% of the principal specialist rate, and the time charged is for the actual time in attendance.

 

Pre-operative assessment is not chargeable and may also not charge for the modifiers 0037 to 0044 or the orthopaedic modifiers 5441 to 5448.

 

Either the principal anaesthesiologist or the assistant anaesthesiologist may charge for the placement of the invasive monitoring lines, namely codes 1215 to1218.

 

The monetary value of modifier 0029 will not be less than 7,00 anaesthetic units (refer to modifier 0035).

 

 

CONSCIOUS SEDATION - MODIFIER 0020:

 

Conscious sedation (CS) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or by light tactile stimulation. A distinction is also made between light sedation and deep sedation (conscious sedation).

 

In light sedation, the patient responds to verbal or tactile stimulae, no airway intervention is required, spontaneous ventilation is adequate and the cardio-vascular function is usually maintained.

 

In deep sedation (conscious sedation) purposeful response is only after repeated or painful stimulae, airway intervention may be required, spontaneous ventilation may be inadequate and cardio-vascular function is maintained.

 

Conscious sedation is therefore seen as an anaesthetic technique. According to a HPCSA Ruling (April 1987 Vol 6 p 295) a medical practitioner 'was not permitted to perform procedures and simultaneously administer the anaesthetic'. If deep sedation (conscious sedation as per the definition above) was provided, a second practitioner had to be present to monitor the patient during the sedation period.

 

The following will apply to conscious sedation cases:

 

 

 

 

 

 

EMERGENCY SURGERY FOR THEATRE PROCEDURES (MODIFIER 0011):

 

Any bona fide, justifiable emergency procedure (all hours), undertaken in an operating theatre, will attract an additional 12,00 clinical units per half-hour or part thereof of the operating time for all members of the surgical team. The conditions as outlined in the use of codes 0146 or 0147 applies.

 

Item 0147 is appropriate for anaesthesiologists/anaesthetists during after-hour periods only where the Compensation Fund is responsible for the account in cases of emergency which may or may not necessitate an anaesthetic (refer to Rule B).

 

 

PAIN MANAGEMENT:

 

Normal post-operative pain management includes oral, intramuscular or intravenous medications. Normal postoperative pain management provided by the surgeon and/or anaesthesiologist is included in the global fee for the surgical procedure.

 

Some procedures and/or patients require more than the usual type of post-operative pain management and this is frequently provided or supervised by an anaesthesiologist. These services are additional procedures and are reported as follows:

 

An Intrathecal or spinal injection for pain management is reported with code 2799.

 

Epidural or sub-arachnoid (code 2801) pain management is reported with the appropriate procedure codes for the placement of an epidural or caudal block.

 

Plexus nerve block (Code 2800) is reported for the following more complex blocks - Brachial plexus block, Cervical plexus block, Axillary nerve block, Multiple ipsilateral intercostal nerve blocks, Sciatic nerve block, Femoral nerve block, Paravertebral block, Psoas compartment block, Celiac plexus block, Phrenic nerve block, Vagus nerve block, Facial nerve block, Trigeminal nerve block, Stellate ganglion block, Superior hypogastric plexus, Sphenopalatine ganglion.

 

Inserting an indwelling nerve catheter (code 2804) is reported if a catheter is inserted with a spinal (code 2799), plexus block (code 2800) or an epidural (code 2801).

 

Patient-controlled analgesia (PCA) is reported with code 1220 plus 1221 if appropriate on a per-day basis. Code 0201 is appropriate for the cost of material used in treatment and is also applicable for disposable PCA devices purchased and provided by practitioners.

 

Indications for use of PCA (intravenous or epidural):

 

 

Post-operative pain management services are not calculated based on time. These services are reported as a single, daily charge.

 

Procedures for chronic pain management (example epidural for pain) is only charged as a consultation service (0173-0175 or 0190-0192} plus the procedure code 2801 plus 2804 if appropriate - note there is no fee for anaesthetic time.

 

 

Epidurals and Spinals

 

 

 

ANAESTHETIC OBSTETRIC GUIDELINES TO BILLING:

 

Epidural insertion for labour

 

Pre-anaesthetic consultation (0151) charged plus 0146 or 0147 (as appropriate) unless elective induction of labour.

 

Time charged using modifier 0023 of actual time spent attending to the patient. usually between 45-60 minutes (8 time units).

 

Epidural PCA is a routine norm for a labouring parturient and procedure code 1220 plus 1221 (if equipment owned by practitioner) is appropriate.

 

When epidural analgesia is administered, an anaesthesiologist may attend to more than one patient. The anaesthesiologist may insert the epidural catheter, start the continuous anaesthetic and leave the patient's bedside. The anaesthesiologist periodically returns to check on the patient or to increase the amount of anaesthetic while attending to other patients who are also receiving epidurals for vaginal deliveries.

 

Once an anaesthesiologist has committed to providing epidural pain relief during labour they are committed to remain available to manage any obstetric emergency.

 

Epidural labour patients progressing to caesarean

 

No additional pre-anaesthetic consultation fee (0151) but 0146 or 0147 as appropriate.

Additional top-up times may be charged for the time spent with the patient prior to admission to the theatre.

Thereafter standard general anaesthetic reimbursement as if a separate procedure.

 

Another consultation service is charged plus 0146 or 0147 as appropriate.

There-after standard general anaesthetic reimbursement as if a separate procedure.

 

 

MODIFIERS TO BE USED IN ANAESTHETICS

 

All anaesthesia services are reported by use of the procedure codes plus the use of other optional modifiers as may be appropriate.

 

A 50% increase in anaesthetic time units for anaesthesiologists.

 

A 50% increase in anaesthetic time units for anaesthesiologists.

 

 

 

 

 

Peri-operative blood salvage is appropriate for the collection of autologous blood intra-operatively and for the administering of salvaged blood (either from cell-saver or re-infusion drains) in the post-operative period.

 

 

Improved surgical exposure (mastoidectomy, tympanoplasty, spinal surgery, major neck dissections, endoscopic sinus drainage, mandibular or maxillary osteotomy, total hip replacement, shoulder surgery).

 

Maintain perfusion pressures (cardiac surgery, craniotomy for tumour/aneursym, major vascular surgery, carotid endarterectomy, major plastic free flaps, vasoactive tumours- phaemochromoctoma/carcinoid syndromes, pre-eclamptic or eclamptic patients, and shocked trauma cases on inotropic support).

 

Invasive monitoring is not regarded as mandatory for the appropriate use of this code.

 

 

 

 

 

 

 

If anaesthetic is administered for procedures on more than one category of bone, the modifier for the highest category of bone concerned is applicable.

 

5441 Add one (1 ,00) anaesthetic unit, except where the procedure refers to the bones named in Modifiers 5442 to 5448.

 

5442 Shoulder, scapula, clavicle, humerus. elbow joint, upper 1/3 tibia. knee joint. patella, mandible and temperamandibular joint: Add two (2,00) anaesthetic units.

 

5443 Maxillary and orbital bones: Add three (3,00) anaesthetic units

 

5444 Shaft of femur: Add four (4.00) anaesthetic units

 

5445 Spine (except coccyx), pelvis, hip, neck of femur: Add five (5.00) anaesthetic units

 

5448 Sternum and/or ribs and musculo-skeletal procedures which involve an intra-thoracic approach: Add eight (8,00) anaesthetic units. Not appropriate for anaesthetic on open heart procedures.

 

 

CHRONIC PAIN MANAGEMENT SERVICES:

 

Chronic pain management services are not anaesthesia services. These are distinct services frequently performed by anaesthesiologists who have additional training in pain management procedures. Pain management services are reported following the same rules as those for surgical procedures.

 

Pain management services include consultative services, trigger point injections. spine and spinal cord injections and nerve blocks. Each code for pain management services should have a specific fee selected from the appropriate codes for the services or procedures rendered. In other words. no adjustments are made based on time, physical status or qualifying circumstances. These codes may be the same as those used for nerve blocks during anaesthesia.

 

 

ANAESTHESIOLOGISTS AS CLINICIANS :

 

It is appropriate for anaesthesiologists acting as clinicians, to charge the appropriate consultation or procedure item when rendering a service not related to the administration of an anaesthetic.

 

Examples are:

 

 

 

SPECIFIC CODES :

 

Code 0100 - Intra-aortic balloon pump: Where an anaesthesiologist would be responsible for operating an intra-aortic balloon pump, a fee of 75,00 clinical procedure units is applicable.

Appropriate as a once-off charge if the anaesthesiologists is in total control of the pump from insertion to removal. A daily charge is not appropriate.

 

Code 0113 - New born attendance: Emergency attendance to newborn at all hours (once per patient) (items 0107, 0109, 0111, 0145, 0146 and/or 0147 may not be added to item 0113).

The specialist fee is appropriate for anaesthesiologists.

 

Code 0133 - Writing of special motivations for procedures and treatment without the physical presence of a patient (includes report on the clinical condition of a patient) requested by or on behalf of a third party funder or its agent.

 

Code 0205 -Intravenous treatment: Intravenous infusions (cut-down or push-in) (patients under three years): Cutdown and/or insertion of cannula -chargeable once per 24 hours.

Chargeable by an anaesthesiologist provided it is not inserted in a theatre environment, i.e. ward, casualty or ICU/Highcare areas.

 

Code 0206 - Intravenous treatment: Intravenous infusions (push-in) (patients over three years): Insertion of cannula - chargeable once per 24 hours.

Chargeable by an anaesthesiologist if they are not the attending doctor either in the ICU/Highcare or involved in the pre- and intraoperative management of the patient, as this fee is included in the pre-operative consult and the fee for critical care services.

 

Code 1321 - Stand-by fee for coronary angioplasty.

Anaesthesiologist need not be present during the procedure, but must be available for resuscitation or emergency CABG surgery.

 

Code 1132 - Bronchoscopy: Diagnostic bronchoscopy.

This code is chargeable by an anaesthesiologist if a diagnostic bronchoscopy is performed or for the confirmation of the correct placement of a double-lumen tube.

 

Code 1356 - Insertion and removal of intra-aortic balloon pump (modifier 0005 not applicable).

This code can only be charged by either the surgeon or the anaesthesiologist. The person actually inserting and removing the IABP can charge the code.

 

Code 1780 - Gastric and duodenal intubation

Appropriate to be charged by the anaesthesiologist if they have inserted the naso-gastric tube.

 

Code 2799 - Procedures for pain relief: Intrathecal injections for pain

 

Code 2800 - Procedures for pain relief: Plexus nerve block

The following more complex nerve blocks will be billable under this code: Brachial plexus block, Cervical plexus block, Axillary nerve block, Multiple ipsilateral intercostal nerve blocks, Sciatic nerve block, Femoral nerve block, Paravertebral block, Psoas compartment block, Celiac plexus block, Phrenic nerve block, Vagus nerve block, Facial nerve block, Trigeminal nerve block, Stellate ganglion block, Superior hypogastric plexus, Sphenopalatine ganglion.

 

Code 2801 - Procedures for pain relief: Epidural injection for pain

 

Code 2802 - Procedures for pain relief: Peripheral nerve block

All other peripheral nerve blocks not mentioned in code 2800.

 

Code 3636 - Trans-oesophageal echocardiography including passing the device

Specialist anaesthesiologists with demonstrated skill and experience may charge this code for recognised intraoperative decision making or diagnostic indications when surgery is not necessarily part of the treatment. In both cases this assumes that problem orientated or a complete study is done and advanced decision making is required.

 

Code 3637 + Colour Doppler (may be added onto any other regional exam, but not to be added to items 3605, 5110, 5111, 5112, 5113 or 5114).

 

Code 5103 - Ultrasound soft tissue, any region

Ultrasound used for the placement of central venous access, arterial lines and nerve blocks can be charged by the anaesthesiologist if he performed the ultrasound.

Please note Rule GG - Capturing and recording of examinations: Images from all radiological, ultrasound and magnetic resonance imaging procedures must be captured during every examination and a permanent record generated by means of film, paper, or magnetic media. A report of the examination, including the findings and diagnostic comment, must be written and stored for five years.

 

Code 5115 - Intra-operative ultrasound study

This code is to be used when anaesthesia or monitored anaesthesia care is required for an ultrasound study to be done.