ASA 2020 Relative Value Guide

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Professional Practice Series

2020 Relative Value Guide8 A Guide for Anesthesia Values

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

Current Procedural Terminology (CPT®), Copyright 1966, 1970, 1973, 1977, 1981, 1983 - 2019 by the American Medical Association (AMA) is a listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians and other qualified health care professionals. This ASA Relative Value Guide® (RVG™) includes only CPT descriptive terms, identifying codes and modifiers for reporting medical services and procedures that relate to the practice of the anesthesiologist. Any user of CPT outside of this Relative Value Guide should refer to the Current Procedural Terminology, as published and copyrighted by the AMA. That publication contains the complete listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians in all areas of medicine. By nature of the medical practice of anesthesiology, anesthesiologists perform a wide variety of services, some specifically related to the delivery of anesthesia care and others including but not limited to evaluation and management (E/M), critical care, pain medicine, intravascular catheterization and transesophageal echocardiography. This 2020 edition of the RVG includes only those codes beyond the range of anesthesia services that are most relevant to anesthesia and perioperative medicine. Also new for 2020, the RVG provides work Relative Value Units (RVUs) rather than base unit values for the non-anesthesia services listed in the RVG. This change does not impact the codes and base unit values assigned to anesthesia care (CPT codes 00100-01999). For more information, please refer to the April 2019 ASA M onitor article - ASA Relative Value Guide (RVG): Updates to Keep it Relevant, Valuable and Germane to Your Practice. Codes that have been removed from the RVG may still be valid CPT codes. If that is the case, then anesthesiologists may continue to report those codes when then provide the service(s) and clinical conditions comply with the rules for reporting the service(s). Anesthesiologists and their practices should understand Medicare and other payers’ coding and coverage rules such as the National Correct Coding Initiative (NCCI). No base unit values, relative values, or relative value guides, guidelines, conversion factors or scales are included in any part of the Current Procedural Terminology by the American Medical Association. The AMA is not recommending that any specific relative values, fees, fee schedules, or related listings be attached to CPT. Any relative value scales or related listings assigned to the CPT codes are not those of the AM A and AMA is not recommending use of these relative values.

©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

Italicized comments within the body of the Relative Value Guide are provided to help clarify code use and are not part of the CPT descriptor. All current codes listed in this edition of the ASA Relative Value Guide are included in the 2020 CPT code set and their use conforms to HIPAA requirements. This guide is best used in conjunction with the ASA CROSSWALK®. The CROSSWALK lists surgical/procedure codes and links them to an appropriate anesthesia code. The Relative Value Guide and the CROSSWALK are updated annually. Anesthesiologists should always use current editions of these publications. Relative Value Guide is a registered trademark of the American Society of Anesthesiologists. RVG is a trademark of the American Society of Anesthesiologists. Copyright © 2019 American Society of Anesthesiologists All rights reserved.

To request a license for distribution of products containing or reprinting Relative Value Guide or to purchase additional ASA Relative Value Guide products, please contact the American Society of Anesthesiologists at 1061 American Lane, Schaumburg, IL 60173 (847) 825-5586.

U.S. Government Rights This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 330 N. Wabash Ave., Suite 39300, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(November 1995) and/or subject to the restrictions of DFARS 227.7202-1 (a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

CPT Copyright 2019 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.

©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

TABLE OF CONTENTS FOREWORD.............................................................................................................vi SUMMARY OF CHANGES......................................................................................vii ANESTHESIA GUIDELINES.................................................................................. xii ANESTHESIA FOR PRCEDURES ON: HEAD...................................................................................................................... 1 NECK...................................................................................................................... 3 THORAX (CHEST WALL AND SHOULDER GIRDLE)..................................... 4 INTRATHORACIC.................................................................................................6 SPINE AND SPINAL CORD.................................................................................9 UPPER ABDOMEN.............................................................................................11 LOWER ABDOMEN............................................................................................13 PERINEUM.......................................................................................................... 16 PELVIS (EXCEPT H IP)...................................................................................... 19 UPPER LEG (EXCEPT KN EE)......................................................................... 20 KNEE AND POPLITEAL AREA......................................................................... 21 LOWER LEG (BELOW KNEE, INCLUDES ANKLE AND FO O T).................. 23 SHOULDER AND AXILLA..................................................................................25 UPPER ARM AND ELBOW................................................................................26 FOREARM, WRIST, AND H AN D ...................................................................... 28 RADIOLOGICAL PROCEDURES......................................................................... 29 BURN EXCISIONS OR DEBRIDEMENT..............................................................31 OBSTETRIC ANESTHESIA...................................................................................32 OTHER PROCEDURES......................................................................................... 34 QUALIFYING CIRCUMSTANCES FOR ANESTHESIA...................................... 35 CONSULTATIVE, DIAGNOSTIC AND THERAPEUTIC SERVICES.................. 36 EVALUATION AND MANAGEMENT SERVICES................................................36 OFFICE OR OTHER OUTPATIENT SERVICES.............................................36 HOSPITAL INPATIENT SERVICES..................................................................41 CRITICAL CARE SERVICES............................................................................ 44 NEWBORN CARE SERVICES.......................................................................... 45 PAIN MEDICINE......................................................................................................46 INTRAVASCULAR CATHETERIZATION PROCEDURES.................................. 57 TRANSESOPHAGEAL ECHOCARDIOGRAPHY................................................59 O THER.....................................................................................................................61 2020 ICD-10-CM CODE BLOCKS......................................................................... 63 INDEX OF ANESTHESIA CODES........................................................................ 74 INDEX OF CONSULTATIVE, DIAGNOSTIC AND THERAPEUTIC SERVICES. 77

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

FOREWORD ANESTHESIOLOGY is the practice of medicine dealing with but not limited to: • The management of procedures for rendering a patient insensible to pain and emotional stress during surgical, obstetrical and other diagnostic or therapeutic procedures. • The evaluation and management of essential physiologic functions under the stress of anesthetic and surgical manipulations. • The clinical management of the patient unconscious from whatever cause. • The evaluation and management of acute or chronic pain. • The management of problems in cardiac and respiratory resuscitation. • The application of specific methods of respiratory therapy. • The clinical management of various fluid, electrolyte and metabolic disturbances. This edition of the Relative Value Guide has been revised and conforms with relevant sections of the Current Procedural Terminology, copyright 1966, 1970, 1973, 1977, 1981, 1983 - 2019 by the American Medical Association. Procedure descriptors and the accompanying CPT five-digit code numbers and two-digit modifiers are identical to those published in CPT. Changes from previous editions of the Relative Value Guide are summarized on pages vii ix.

ASA Committee on Economics Christopher A. Troianos, M.D., FASA, FASE, Chair Amr E. Abouleish, M.D., M.B.A., FASA Asokumar Buvanendran, M.D. Alexander Choi, M.D., M.P.H., FASA Denise Cinquegrana, M.D., M.P.H. Neal H. Cohen, M.D., M.P.H., M.S. Stephen Comess, M.H.S.A. Zev Davidovich, M.D. Peter DeSocio, D.O., M.B.A., CPE, FASA Jonathan S. Gal, M.D., FASA Peter Goldzweig, D.O., FASA Padma Gulur, M.D. H. David Flardman, M.D., M.B.A., FASA Jeffrey Kirsch, M.D., FASA Marc L. Leib, M.D., J.D. Michael Lewis, M.D., FASA

David P. Martin, M.D., Ph.D., FASA Jana McAlister, CAA Gordon Morewood, M.D., M.B.A., FASA, F Jeff Mueller, M.D., FASA Sonya M. Pease, M.D., M.B.A., FASA Johnathan L. Pregler, M.D. Scott Roethle, M.D., FASA Richard Rosenquist, M.D. Vijay Saluja, M.D., M.B.A., FASA Stanley W. Stead, M.D., M.B.A., FASA Kenneth R. Stone, M.D. Alan F. Strobel, M.D., M.B.A., CPC, FASA Kevin Vorenkamp, M.D., FASA Eric Werner, M.D., FASA Christopher J. Young, M.D., FASA S h arn n

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©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

SUMMARY OF CHANGES NEW CODES: CPT Code

CPT Descriptor

62328

Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance

62329

Spinal puncture, therapeutic, for drainange of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance

64451

Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

64454

Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

64624

Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

64625

Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

REVISED CODES: CPT Code

CPT Descriptor

62270

Spinal puncture, lumbar, diagnostic;

62272

Spinal puncture, therapeutic, for drainange of cerebrospinal fluid (by needle or catheter);

64400

lnjection(s], anesthetic aaent(s) and/or steroid; trigeminal nerve, any d ivision or branch each branch (ie. ophthalmic, maxillary, mandibular)

64405

lnjection(s), anesthetic aaent(s) and/or steroid; greater occipital nerve

64408

lnjection{s), anesthetic aaent(s) and/or steroid; vagus nerve

64415

Iniection(s). anesthetic aaent(s) and/or steroid; brachial plexusi-smgle

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

CPT G

64416

lnjection{s), anesthetic aoent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement)

64417

Iniection(s), anesthetic aqent(s) and/or steroid; axillary nerve

64418

lnjection{s), anesthetic aaent(s) and/or steroid: suprascapular nerve

64420

lnjection[s), anesthetic aqent(s) and/or steroid; intercostal nerve, single level

64421

lnjection(s], anesthetic aqent(s) and/or steroid; intercostal nerve, multiple, regional block each additional level (List separately in addition to code for primary procedure)

64425

Iniection(s), anesthetic aqent(s) and/or steroid; ilioinguinal, iliohypogastric nerves

64430

lnjection(s], anesthetic aqent(s) and/or steroid; pudendal nerve

64435

lnjection[s), anesthetic aqent(s) and/or steroid: paracervical (uterine) nerve

64445

lnjection{s], anesthetic aqent(s) and/or steroid; sciatic nerveT stogie

64446

lnjection(s], anesthetic aqent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement)

64447

Injectionfs], anesthetic aqent(s) and/or steroid: femoral nerveT stogie

64448

lnjection(s], anesthetic aqent(s) and or steroid: femoral nerve, continuous infusion by catheter (including catheter placement)

64449

lnjection(s], anesthetic aqent(s) and/or steroid: lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)

64450

Injection(s), anesthetic aqent(s) and/or steroid: other peripheral nerve or branch

©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

REVISED MODIFIER: CPT Modifier

CPT Modifier Descriptor

50

Bilateral Procedure: Unless otherwise indentified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. Note: This modifier should not be appended to designated “add-on” codes.

DELETED CODES: CPT Code

CPT Descriptor

64402

Injection, anesthetic agent; facial nerve

64410

Injection, anesthetic agent; phrenic nerve

64413

Injection, anesthetic agent; cervical plexus

NEW/REVISED RVG CODING COMMENTS: Italicized comments within the body o f the Relative Value Guide are provided to help clarify code use and are not part o f the CPT code descriptor. CPT Code

00326

CPT Descriptor

Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age (RVG Comment: Base unit value takes patient age into consideration.)

(RVG Comment: Except Excludes tracheobronchial reconstruction. For tracheobronchial reconstruction, report code 00539.)

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

ALL REVISIONS CONTAINED IN THIS RELATIVE VALUE GUIDE WILL BE FOOTNOTED IN THE FOLLOWING MANNER: • ▲ ♦

■ > +

#

Indicates this is a new CPT code. Indicates the descriptor has changed. Indicates the Centers for Medicare & Medicaid Services (CMS) uses a different base unit value. (CMS base units apply to payment made under the Medicare Physician Fee Schedule [MPFS]). Indicates the base unit value or the work RVU has changed. Indicates a new/revised RVG Comment. Indicates an add-on code. (An add-on code describes care provided in addition to the prim ary procedure. It should not be reported on its own but always along with a prim ary procedure code.) Resequenced CPT code.

ABBREVIATIONS USED IN THIS RELATIVE VALUE GUIDE INCLUDE: TM IC

Indicates that the use of time is appropriate. Indicates “individual consideration" is appropriate.

©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

ASA STANDARDS AND GUIDELINES RELEVANT TO CODING/BILLING: Current versions of the documents listed below are available on the ASA website at www.asahq.org Position on Monitored Anesthesia Care Distinguishing Monitored Anesthesia Care (“MAC”) From Moderate Sedation/Analgesia (Conscious Sedation) Statement on Intravascular Catheterization Procedures Statement on Transesophageal Echocardiography Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia Statement on Anesthetic Care During Interventional Pain Procedures for Adults Definition of “Immediately Available” When Medically Directing Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia The Medical Necessity of Anesthesiology Services American Society of Anesthesiologists’ Position Statement Statement on Documentation of Anesthesia Care ASA Physical Status Classification System

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

ANESTHESIA GUIDELINES This is a relative value guide and not a fee schedule. This guide does not suggest the monetary value of any unit or the dollar amount of any individual’s charges. It is designed to provide assistance to individual anesthesiologists in the development of their fee schedules for their professional services. These relative values do not take into account, and do not include, the cost of drugs and supplies. Any changes in this most recent edition are not intended to suggest that anesthesia fees for the procedures or other professional services in question should be altered. This guide is best used in conjunction with the ASA CROSSWALK. The CROSSWALK lists surgical/procedure codes and links them to an appropriate anesthesia code. The Relative Value Guide and the CROSSWALK are updated annually. Anesthesiologists should always use current editions of these publications. The values in this guide apply when anesthesia care is provided by or under the medical direction of an anesthesiologist. This care may include but is not limited to general anesthesia, regional anesthesia, monitored anesthesia care, or other services to provide the patient the medical care deemed optimal. The use of a brain function monitor for intraoperative awareness as defined in the ASA Practice Advisory for Intraoperative Awareness and Brain Function Monitoring; www.asahg.org is not separately reportable in conjunction with an anesthetic service. A service that is rarely provided, unusual, variable, or new may require a special report indicating the service’s medical appropriateness. The necessity of assistance by a second anesthesiologist should be substantiated by a special report indicating the circumstances that required the need for two physicians. All anesthesia values are determined by adding a Base Unit Value, which is related to the complexity of the service, with any Modifying Circumstances plus Time. I.

Base Unit Value: A base unit value is listed for anesthetic management of most surgical procedures. This includes the value o f all usual anesthesia services except the time actually spent in anesthesia care and any modifiers. Usual anesthesia services incorporated in the base unit \ / a ll IO

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©2019 American Society of Anesthesiologists

2020 Relative Value Guide®

and interpretation of non-invasive physiologic monitoring. Placement of arterial, central venous and pulmonary artery catheters and use of transesophageal echocardiography (TEE) are not included in the base unit value. When multiple surgical procedures are performed during a single anesthetic administration, only the anesthesia code with the highest base unit value is reported. (The time reported is the combined total for all procedures.) Add­ on anesthesia codes are an exception to this policy. They are listed in addition to the code for the primary procedure. W henever access to the airway is limited (eg, 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. Refer to the text in Modifier 22, page xvi. II.

Anesthesia Modifiers: All anesthesia services are reported by use of the anesthesia five-digit procedure code plus the addition of a physical status modifier. These modifying units may be added to the base unit values. The use of other optional modifiers may be appropriate. A.

Physical Status modifiers are represented by the initial letter P followed by a single digit from 1 to 6 defined below: Modifier Descriptor P1 - A normal healthy patient

Base Unit Value 0

P2 - A patient with

mild systemic disease

0

P3 - A patient with

severe systemic disease

1

P4 - A patient with severe systemic disease that is a constant threat to life

2

P5 - A moribund patient who is not expected to survive without the operation

3

P6 - A declared brain-dead patient whose organs are being removed for donor purposes

0

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of n f f h a o n o c f h o c i a c o rx / ip p nrnx/iH pH

2020 Relative Value Guide®

© 2019 American Society of Anesthesiologists

ASA PHYSICAL STATUS CLASSIFICATION SYSTEM Last approved by the ASA House of Delegates on October 23, 2019 The ASA Physical Status Classification System has been in use for over 60 years. The purpose of the system is to assess and communicate a patient’s pre-anesthesia medical co-morbidities. The classification system alone does not predict the perioperative risks, but used with other factors (eg, type of surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks. The definitions and examples shown in the table below are guidelines for the clinician. To improve communication and assessments at a specific institution, anesthesiology departments may choose to develop institutionalspecific examples to supplement the ASA-approved examples. The examples in the table below address adult patients and are not necessarily applicable to pediatric patients. Assigning a Physical Status classification level is a clinical decision based on multiple factors. While the Physical Status classification may initially be determined at various times during the preoperative assessment of the patient, the final assignment of Physical Status classification is made on the day of anesthesia care by the anesthesiologist after evaluating the patient.

Current Definitions and ASA-Approved Examples) ASA PS Classification ASA 1

Definition A normal healthy patient A patient with mild systemic disease

ASA II

A patient with severe systemic disease ASA III

Adult Examples, Including, but not Limited to: Healthy, non-smoking, no or minimal alcohol use Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30

©2019 American Society of Anesthesiologists

ASA IV

ASA V

A patient with severe systemic disease that is a constant threat to life

A moribund patient who is not expected to survive without the operation

2020 Relative Value Guide®

undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of Ml, CVA, TIA, or CAD/stents. Examples include (but not limited to): recent (