September 5, 2023

Last week, we brought you an alert on certain strategies being used by anesthesia groups across the country to enhance their revenue opportunities. We discussed acute pain, chronic pain, adding new places of service and experimenting with ketamine clinics. In keeping with this theme, there is another avenue of additional reimbursement potential that some practices are now pursuing: presurgical testing. What does this service entail, and what can anesthesia groups expect to reap by adding this component to their line of services?

Defining Our Terms

Over the years, we have noticed a growing interest within the anesthesia community in the concept of presurgical clinics. Often, this interest was sparked by a speaker at a state or national event or by a hired consultant who presented the idea to the group as a can’t miss revenue opportunity. Essentially, these clinics perform what is sometimes called pre-anesthesia testing (PAT) or presurgical clearances on patients who are scheduled for various surgeries—surgeries that will ultimately involve anesthesia services. For convenience, we will use the acronym PAT to identify this service.

In many cases, it is not the anesthesia providers performing the PATs. Rather, the group hires a nurse practitioner (NP) to see the patient, perform the testing (eg, vitals, blood work, etc.), and generally evaluate the patient to determine if he or she can be expected to successfully withstand the scheduled procedure. For example, if the upcoming surgery involves the cardiovascular system and the surgeon has reason to believe the patient may have difficulty with the surgery or the anesthesia, the surgeon may refer the patient to the PAT clinic to get a full workup and recommendation as to the suitability of the patient for the operative session.

Determining the Propriety

Seeking to add value to the group in the eyes of the surgeons and hospital administration is certainly commendable. And looking for ways to add another revenue stream in this financially challenging time is quite understandable. The PAT clinic concept would seem to check both of these boxes. There are, however, some factors that anesthesia groups should take into consideration before dipping their toe into these waters.

The first thing to consider is the propriety of this arrangement. How appropriate is it for an anesthesia group to submit a claim for evaluating a patient in connection with a scheduled case for which the same anesthesia group will be billing for anesthesia services? The anesthesia provider is already required to perform a pre-anesthesia assessment (PAA) prior to the anesthesia service. That PAA is bundled into the anesthesia code that appears on the claim form. In other words, the PAA is not separately billable. But now we have this additional evaluation, in the form of a PAT session, for which anesthesia providers are seeking separate payment.

Typically, claims for these services would be submitted with a relatively low-paying evaluation and management (E/M) code. And, of course, groups will have to provide human resources to staff the clinic and perform these pre-surgical clearances. The question is this: are the compliance risks and resource requirements worth the reward?

There are three typical ways in which an anesthesia provider obtains payment from the E/M code set: (a) a postoperative pain round, (b) the PAA where the case was canceled prior to induction, and (c) an anesthesia consult. In scenario “a,” the service is separate and apart from the anesthesia service. In scenario “b,” the PAA that is usually bundled becomes payable only because the anesthesia service never took place. In scenario “c,” the consult is only payable if it represents a service that is above and beyond the bundled PAA. The question is, does the PAT constitute an anesthesia consult; and, if so, does it meet above-and-beyond criterion?

To answer the above questions, we need to determine the following: (a) who is performing the PAT, and (b) what does this evaluation service actually entail? According to the Medicare State Operations Manual in its treatment of the conditions of participation (CoPs)—that is, the conditions that hospitals have to meet in order to participate with Medicare—we are given a list of provider types that are authorized to perform a PAA. That list does not include an NP. A nurse practitioner is not an anesthesia provider, so an NP cannot perform a pre-anesthesia assessment. It follows that an NP cannot also perform an anesthesia consult. If these PATs are essentially an anesthesia consult, then it is entirely inappropriate for such services to be performed by the NP.

If these PATs or presurgical clearance screenings are not an anesthesia consult, then what are they? Our understanding is that patients undergoing these screenings are being referred to the anesthesia group by the patients’ surgeons. Again, the purpose is purportedly to check out whether the patient is a legitimate candidate for surgery and/or anesthesia. But why isn’t the surgeon doing this? Isn’t this determination part of the surgeon’s own health and physical (H&P) exam prior to surgery? Why does there need to be an additional step in the process—additional to the surgeon’s H&P and the anesthesiologist’s PAA? Furthermore, if the PAT service is more analogous to an H&P than the PAA, why is the anesthesia group’s NP more competent to perform this service than the patient’s own surgeon? The point we’re trying to make here is that some payers may eventually question the medical necessity of this supplemental and relatively amorphous evaluative service (in addition to the bundled H&P and the bundled PAA).

Proceed with Caution

Despite the concerns addressed above, the case can be made that the service being provided in these PAT clinics may be deemed medically appropriate and thus payable in at least some instances. As with anesthesia consults, claims for these screenings should not be routine, i.e., not submitted for every patient or just any patient. In assessing both the risk and opportunity relative to presurgical testing services, one anesthesia compliance attorney has indicated the following:

1. Preoperative assessments can be billed, provided that very rigid controls and prerequisites are implemented and followed, and further provided that the anesthesia group has a tolerance for some risk.
   
   
2. As to the risk, S. v. Chen, a False Claims Act (FCA) case, may be somewhat instructive. The case was brought against Dr. Chen, an anesthesiologist, for submitting consultations (the highest consult code available) for each of his anesthesia cases. The jury found that he submitted over 3,500 claims inappropriately, and the court of appeals affirmed. So, if claims for PAT services are (a) deemed to be akin to an anesthesia consult claim, and (b) submitted routinely, it could result in an FCA action.
   
   
3. The Chair of the Committee on Economics for the American Society of Anesthesiologists (ASA) wrote an article in 2014, explaining the circumstances under which the ASA believes these PAT-type services can and cannot be billed, as follows:
1. The service must be significantly above and beyond the usual pre-anesthesia eval, and as such would need to address items that are not addressed in the routine pre-anesthesia eval.
2. The conditions examined could include a comprehensive exam of the patient’s entire medical condition, as well as management of those issues that need to be corrected or optimized prior to surgery.
3. These visits would be billed “under rare conditions.”
    
4. Where the PAT or pre-surgical clearance clinic sees a large percentage of surgical candidates, such as all those with a physical status indicator of III or higher, the provider of the PAT services may pop up on the payer’s radar, and an audit may ensue. The provider and/or group would need to be able to accept that risk.

Of course, the above does not directly address the scenario where an NP employed by the anesthesia group is the one who is performing the bulk of these screenings. Since an NP cannot perform an anesthesia consult, any evaluative work performed by the NP may be deemed by the payer (or the government) as necessarily outside the scope of the PAA and thus not an attempt to unbundle the PAA. Nevertheless, it would be wise for anesthesia groups that are looking to employ NPs for this very purpose to recognize there is risk and that such services should not be routine.

If you have further questions about PAT clinics, please contact your account executive.

With best wishes, 

Rita Astani
President—Anesthesia