January 14, 2019

Anesthesia providers should be aware of two changes in the ASA 2019 Relative Value Guide^® (the book of descriptors for anesthesia services, base unit values and CPT codes) with potential implications for their practices.

First, the 2019 RVG includes modifications in the specialty’s approach to field avoidance.  The revision removes the longstanding references to unusual patient positioning and anatomical location in relation to field avoidance as a qualifying circumstance.  For years, including 2018, the RVG stated [boldface highlights are ABC’s]:

Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum base value of 5 regardless of any lesser base value assigned to such procedure in the body of the Relative Value Guide.

The new guidance refers to field avoidance solely in terms of lack of immediate access to the airway.  The 2019 revision more broadly states:

Whenever access to the airway is limited (e.g., field avoidance), the anesthesia work required may be substantially greater compared to the typical patient.  This anesthesia care has a minimum base unit value of 5 regardless of any lesser base unit value assigned to such procedure in the body of the Relative Value Guide.

Note that the definition does not mention the positon of the patient.  The position of the patient no longer is a criterion for additional units.

A review of all the procedure codes with a base unit value of less than 5 units reveals some of the procedures that could have field avoidance  include some around the head and neck, such as:

HEAD
00124 – Otoscopy
00126 – Tympanotomy
00164 – Nose and accessory sinuses biopsy, soft tissue

NECK
00322 – Needle biopsy of thyroid 00454 – Biopsy of clavicle

If a patient is in the prone position and general anesthesia is used, this could cause the anesthesia provider to have limited access to the airway.

The new guidance essentially means that anesthesia practitioners will have fewer opportunities to bill for field avoidance than in the past. A base 3 or 4 procedure with the patient in the prone position will no longer qualify for field avoidance, unless the anesthesia provider encounters difficulty accessing the airway during the procedure.

The majority of procedures that are likely to involve lack of access to the airway have a base unit value of at least 5; few procedures with a base value of 3 or 4 involve airway access issues.

Field avoidance is essentially an unbillable item.  However, the option remains that claims for procedures with a base unit value less than 5 involving limited airway access can be submitted to some payers with the appropriate modifier.  In these cases, supporting documentation must be submitted that substantiates the increased complexity of the anesthesia services provided. 

The other significant change to the 2019 RVG pertains to the definition of anesthesia time.  The revised definition incorporates, for the first time, the concept of discontinuous time. The previous definition stated:

Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

However, according to the 2019 RVG:

Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient.  It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care.  Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service.  In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

In our in-services with clients, we refer to "the relationship of dependency between the patient and provider" in describing an effective approach to the proper documentation and billing of anesthesia time.  The patient’s relationship with the anesthesia provider is one of dependency. In essence, this means that the documentation must show that the anesthesia provider (or another member of the anesthesia department) was with the patient the entire time of billing.

For example, when anesthesia is provided via a regional or block technique and the patient may be safely observed by a non-anesthesia professional between the time the block is administered and the start of the surgical intervention, this time should not be billed.  However, the bundling of discontinuous time, either before or after the interruption, is billable.  A member of the anesthesia department must be present with the patient for the time to be billable.

ABC clients:  If you have any questions on these changes to the 2019 RVG, your account executive will be glad to assist you.

We want to hear from you.  Do you have a topic you would like to see covered in an ABC eAlert?  Please send your suggestions to info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO