Medical Coverage Policies

Description of Service

When a service involves multiple surgical procedures by the same professional provider, in the same setting, and on the same date of service, surgery reduction guidelines will apply.

Reimbursement Policy

Multiple surgical procedures (modifier 51): Procedures performed during the same operative session by the same provider are reimbursed at 100% of the regular, reasonable, and customary amount for the primary or first surgical procedure and 50% of the regular, reasonable, and customary amount for each secondary procedure.

Bilateral procedures (modifier 50): Procedures performed on both sides of the body during the same operative session are reimbursed at 100% of the regular, reasonable, and customary amount of the first surgical procedure and 50% of the regular, reasonable, and customary amount of the secondary procedure.

Exclusions: The above policy will not apply to procedures which are modifier 51 exempt based on AMA CPT Guidelines. The policy does not apply to procedures determined to be not medically necessary.

The following payment policies apply to medically necessary anesthesia services rendered by in-network or out-of-network providers. The eligibility of benefits for anesthesia services is based on the specific plan provisions or exclusions. Anesthesia services are normally covered when rendered in conjunction with covered surgical procedures.

Description of Service

Anesthesia is the administration of a drug or anesthetic agent by an Anesthesiologist, Certified Registered Nurse Anesthetist, or an Anesthesia Assistant for medical or surgical purposes to obtain muscular relaxation or to induce partial or total loss of sensation to a surgical site or to obtain total loss of consciousness.

Billing and Reimbursement

Anesthesia services can be billed using the following AMA Current Procedural Terminology.

• Anesthesia Services (CPT Codes 00100 – 01999)
• Moderate (Conscious) Sedation (CPT Codes 99143 – 99150)
• Anesthesia add on codes are reported in addition to their primary anesthesia code.

Services rendered by out-of-network providers will be reimbursed using the following relative value calculation.

• Base Units + (Time Units X Conversion Factor) = Regular, Reasonable & Customary Allowance.

Supervision of a CRNA by an anesthesiologist will only be considered for reimbursement if the modifiers of QK or QY are appropriately appended to the billed anesthesia procedure. Services billed by the CRNA must include the appropriate modifier of QX or QZ. When services are billed by both the anesthesiologist and the CRNA, for the same anesthetic service, reimbursement will be split (50%-50%) between the supervising anesthesiologist and the CRNA.

General Information

Pekin Life Insurance Company reimburses medically necessary services, provided in the most cost effective setting for the services needed. All policy language for coverage applies.

Benefit Information

General benefit information may be verified by faxing a request to 1-309-346-8265. The information will be returned by fax within twenty four (24) working hours.

Insured’s Responsibility

An insured may be liable for any of the following:

• Deductible
• Co-insurance
• Copayment
• Usual & Customary disallowed amounts
• Non-covered services