Anesthesia Asks: Who Are COVID-19 Patients?
Summary:
There is still much about the coronavirus that we don't understand. Physicians pride themselves on being able to diagnose problems and classify them precisely. In this sense, and in getting paid for the services rendered to these patients, this virus is still somewhat of a mystery that still needs to be sorted out.
An eminent biology professor at Georgetown University, Father Bauer, was known for reminding his students that if they could agree on the problem, they would be able to agree on the solution. That maxim may prove useful in helping us to deal with the current crisis we're facing in healthcare. Providers confronted with a challenge that appears to defy categorization, especially for the anesthesia provider. As a respiratory virus, COVID-19 is not only insidious; it is protean. One never knows exactly how severe the virus will be or what systems will be affected. Most patients never show any symptoms while others suffer horribly.
Not only is the patient at risk, but so, too, the provider. Because of the respiratory complications of many of these patients, anesthesia providers are being asked to address a variety of airway complications. The good news is that the number of patients suffering from respiratory distress is not as great as was anticipated—especially for the majority of our clients. The bad news is that many don't make it.
Looking at the Numbers
A review of our database revealed a number of interesting things. First, the number of patients where the record confirmed a diagnosis of COVID-19 was considerably lower than anticipated, amounting to just over 1,000 patients. In part, this could be explained by the fact that the following COVID-19 diagnoses were not introduced until April 1, and technically the first wave of patients started to appear the third week in March.
- U07.1 COVID-19
- B97.29 Other coronavirus as the cause of diseases classified elsewhere
The onset of the pandemic was heralded by the use of three codes: 31500 for emergency intubations, 99291 for ICU care and 99233 for complex hospital visit care. Weekly increases in the volume of these three codes was clearly reflective of care provided to COVID-19 patients. The chart below clearly highlights the change in volume for emergency intubations and the corresponding diagnoses.
The table below reveals the range of diagnoses being captured from the patient's chart by our coding team. Obviously, the missing piece here is a definitive determination of the patient's virus status, which will not be resolved until a much higher percentage of patients actually gets tested. The result is that we have COVID and COVID-like patients.
Reflection and Recovery
Clearly, the precipitous impact of this virus has been both disruptive and devastating to all levels of society. Most Americans had never heard of quarantine much less experienced it. The impact of a virtual national lockdown pushed Congress into overdrive, resulting in the passage of four pieces of stimulus legislation intended to keep people afloat as the infection spreads and the death toll rises. The real question is not when the lockdown will end but what life will look like in a post-lockdown era. Clearly, it will not be business as usual.
As is so often the case in a situation like this, recovery is a piecemeal process. Attempts at restoration move from the general to the specific. Congress passed some very significant legislation and passed out huge sums of money. Many an anesthesia practice was the beneficiary of the Payroll Protection Program (PPP), SBA loans, the Medicare payment advance, and stimulus grants (with a second round to be delivered this month for those who applied); but these are just stopgap measures. We are all waiting for our clients to start doing cases again; and there is considerable optimism that surgical volumes will pick up quickly. However, from discussions with some of our clients, it appears that in most areas this will be a slow ramp-up, in order to adhere to clinical guidelines and to provide facilities flexibility in the event they need to ramp back down due to a COVID-19 spike in a given area.
What then will be the impact of the unbelievable unemployment numbers? Will patients have any money left to pay their medical bills? That will be the question. Many plans are excusing the patient portion of the allowable for COVID-related services, but this will not be the case for elective, non-COVID surgeries.
For the Uninsured
The president has signed into law the Families First Coronavirus Relief Act (FFCRA) that includes provisions for payment to providers who treat uninsured COVID-19 patients as of February 4. The program will pay for services provided based on Medicare rates. To get paid, providers must enroll. ABC and Medac are assisting in the registration process. Providers must also agree to accept the payment as payment in full. They cannot balance bill the patient. While our data does not indicate a large percentage of patients meet the criteria for this program, we are making every effort to collect every dollar due for these patients. The majority of patients that are being treated are either Medicare or Medicaid. At this time, the program is processing electronic claims through Optum, and they will determine if the claim is accepted and paid. All of the decisions on claims are final, as there is no appeal process. Claims can be submitted as of May 6. The program does not have an unlimited source of funding; therefore, we will be processing claims regularly until we get further guidance from CMS.
In Conclusion
It is the nature of anesthesia care that for all the planning and preparation there is always an element of risk; hours of boredom punctuated by moments of sheer terror. Historically, though, anesthesia providers have only had to consider factors present in the operating room—the patient's condition, the requirements of the surgeon and the provider's preferences—but now what happens in the operating room is greatly influenced by what happens outside and in the community as a whole. While the coronavirus may have arrived as a moment of sheer terror, little by little, the details of its impact are starting to be sorted out. While the number of actual patients may be relatively small, the impact has been significant. Let us hope that case volumes start to pick up quickly and that we can all return to some semblance of normalcy; although it is now quite clear that the legacy of this virus will impact us all for a long time to come.
As always, should you have any questions, please reach out to your Client Manager or email us at info@anesthesiallc.com.