The Centers for Medicare and Medicaid Services (CMS) Contractor Medical Directors (CMDs) recently put together a list of common CMS claim issues that were of concern to various contractors. Several of these items involve services that may impact anesthesia or pain management providers. 1. Use of modifier -59 for imaging with those procedures that now INCLUDE imaging in the code description and payment e.g. paravertebral joint/nerve blocks; transforaminal epidurals, many others. In some cases, the base procedure includes fluoroscopy or CT imaging and the provider decides to perform the service under ultrasound guidance. Since the ultrasound guidance is not “bundled” in the base procedure description, coders are incorrectly appending modifier 59. However, the base procedure includes the payment for the fluoroscopy or CT imaging. It is incorrect to substitute the required and bundled imaging for another type that is not bundled and bill it separately. 2. Billing for “not qualified” personnel...

As happens every year, Congress stepped in at the last minute and blocked the Sustainable Growth Rate (SGR) cuts in Medicare payments to physicians.  On the afternoon of January 1, 2013, the House of Representatives adopted legislation passed earlier that day by the Senate, the "American Taxpayer Relief Act of 2012.” The bill prevented a plunge over the “fiscal cliff” by postponing across-the-board spending reductions and also overrode the 26.5 percent Medicare fee schedule cut that technically had already gone into effect on the morning of passage.   Congress’ action replaced the SGR reduction with a zero percent update for services provided from January 1, 2013, through December 31, 2013. Because of adjustments in the practice expense component of the anesthesia conversion factor (CF), the 2013 national average CF is $0.50 higher than last year’s CF, i.e., $21.9243.  This is 38 percent higher than the $15.93 CF announced in November 2012.   Actual...

The 2013 CPT® Changes and Codebook are now available to health care providers.  Overall, the 2013 changes include 186 new codes, 119 deleted codes, and 263 revised codes. In addition CPT revised 18 modifiers and updated 150 guidelines.  The very good news for anesthesia and pain management providers is only a small handful of these changes directly impact the services they routinely provide.  Following are general comments regarding the 2013 changes: No Anesthesia codes were deleted, revised, or added for 2013.Pain management providers should take note of the four revised codes and one new code in the nervous system section of CPT 2013. The majority of changes occur in the denervation subsection, where CPT revised codes 64612 and 64614 and added 64615 for bilateral chemodenervation of muscles innervated by the facial, trigeminal, cervical spinal and accessory nerves.CPT also changed the parenthetical note for code 76942, ultrasound guidance for needle placement (eg,...

  MEDICARE PAYMENTS AFTER DECEMBER 31st If we go into the New Year without legislation to stop the economy from going over the fiscal cliff—as appears almost certain—there will be no just-in-time SGR fix either.  The Medicare conversion factor applicable to services provided from January 1st onwards will be 26.5% lower, unless and until Congress corrects the problem.  Since the earliest that Medicare will pay claims will be January 14th, however, there is time for Congress to take the necessary action and prevent any remittances from going out at the lower rate, subject to later adjustment.   It is instructive to look at a six-year history of the dates on which Congress passed legislation each year avoiding the impact of the SGR (American Medical News, December 24, 2012): 2006-4.4%0.2%Feb. 8, 2006* 2007-5%0%Dec. 20, 2006 2008 (Jan.–June)-10.1%0.5%Dec. 29, 2007 2008 (July–Dec.)-10.6%0%July 15, 2008* 2009N/A1.1%N/A 2010 (Jan.–Feb.)-21.3%0%Dec. 19, 2009 2010 March-21.3%0%March 2, 2010* 2010...

  In a much awaited pronouncement, on June 1, 2012, the U.S. Department of Health and Human Service’s Office of Inspector General issued Advisory Opinion 12-06 addressing the propriety of two popular schemes to extract money from anesthesiologists, the so-called “company model” and the purported “management fee.” The advisory opinion could not be more welcome: Just as Willie Sutton, the bank robber, targeted banks “because that’s where the money is,” owners of ambulatory surgery centers continue seek a share of anesthesia fees. According to a survey conducted by the American Society of Anesthesiologists, 41% of the responding anesthesia practices (125 out of 308) reported being requested by an ASC or its referring physician practice to adopt a company model. Not surprisingly, those 125 practices reported that out of the total 332 requests to participate in a company model entity, the group lost the contract in at least 159 instances. Company Model...