Edit 00690

Anesthesia Units Greater Than Max

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: M53
HIPAA Healthcare Claim Status Code: 251
    Entity Identifier Code: N/A

Potential Causes:
Anesthesia Time was not submitted in the correct format. New York State Medicaid processes claims for Anesthesia according to units of service. Each 15 minutes of Anesthesia Time equals one unit. In addition, each procedure code billed has an Anesthesia Value, which is added to the number of units. The total number of units (time in 15 minute increments, 1 unit =15 minutes) plus the Anesthesia Value associated with the procedure code equals the number of units entered on the claim.

Solution:
Check to ensure you should be billing for Anesthesia Time. If not, remove the modifier for Anesthesia. Check the number of units entered for Anesthesia Time, and verify that the number entered was arrived at according to the above formula. Resubmit your claim using the loops and segments below. (Note: The claim can be resubmitted on paper with the supporting documentation in order to get paid the actual number of units, which might be more than the max allowed.)

837 Professional

Loop 2400, SV1 (Professional Service) SV101-1 = HC (Product/Service ID Qualifier) SV101-2 = Procedure Code (Product/Service ID) Loop 2400, SV1 (Professional Service) SV101-3 = Procedure Modifier - Enter HCPCS procedure code modifier SV101-4 = Procedure Modifier - Enter HCPCS procedure code modifier SV101-5 = Procedure Modifier - Enter HCPCS procedure code modifier SV101-6 = Procedure Modifier - Enter HCPCS procedure code modifier Loop 2400, SV1 (Professional Service) SV104 = Enter the service unit count (Quantity)