Deterrents and Detours: Anesthesia’s Pathway to Pain Payment

On a recent trip through the Ozarks, attempting to reach a trout-filled river, our caravan of two vehicles was being guided by a GPS device that began to dole out dubious directions. All of a sudden, we found ourselves on a rut-filled gravel road that promised to go on for miles. The lead car kept going, though now at a snail's pace. The driver of the rear vehicle, however, was having none of it. He had just purchased a customized sportster and was not about to get it banged or dinged on the increasingly sketchy cow path. After turning around and getting back on the main road, we wound up getting to our destination at the same time as those taking the AI-inspired "fastest route."

Often in the practice of anesthesia, things will be rolling along quite smoothly when, all of a sudden, some payer policy or government regulation will throw up a roadblock to quick reimbursement. You've provided the care and played by the rules, but there is the inevitable attempt by some to sabotage your earnings through denial or delay. These deterrents to payment are part of a stepped-up strategy on the part of a growing number of payers—especially as it concerns ancillary services, such as post-operative pain.

In this latest installment of alerts focusing on the acute pain portion of anesthesia practices, we will be looking at the newest obstacles set before us and how those obstacles can be overcome. As your billing partners, we are committed to helping you navigate around such challenges and find new pathways to payment.

A Bumpy Ride

Over the last couple of years, two major players on the health insurance scene have made it increasingly difficult for providers to obtain payment for their post-operative pain blocks. These payers implemented what amounts to a pre-screening edit of the -59 modifier. As you may know, this 2-digit numeric identifier is appended to the post-operative pain code(s) on the claim form, identifying it as a procedure that is separate and apart from the anesthesia service and thus eligible for separate reimbursement. In other words, the whole point of adding this modifier to the procedure code is to bypass the carrier's payment edits, so that the additional service will get paid.

The problem is that, instead of automatically reimbursing the additional service(s), such as an acute pain block and its associated ultrasound (USG), these two national payers are now routinely requesting additional information (e.g., op notes, USG reports) before processing the service(s). Even after receiving the additional documentation, it's often a game of roulette with these carriers. Sometimes they pay; sometimes they don't. In either case, your accounts receivable (AR) may be affected by the increasing capriciousness of these carriers.

The deterrents to swift reimbursement being put up by these two prominent health insurers are reason enough for concern; but how long will it be before others follow their lead? Apparently not long at all. We have received word from the Virginia affiliate of another national health insurance behemoth that, beginning next month, they too will be implementing a pre-payment screening of codes billed with the -59 modifier. Anthem of Virginia sent out a communication this summer containing the following advisement:

Effective with dates of service on or after October 1, 2019, we will update our audit process for claims with modifiers used to bypass claim edits by conducting modifier reviews through a pre-payment clinical validation review process. Claims with modifiers such as -25, -57, -59, LT/RT, and other anatomical modifiers will be part of this review process.

In accordance with reimbursement policies which document proper usage and submission of modifiers, the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing (such as National Correct Coding Initiative). Clinical analysts who are registered nurses and coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.

We do not know at this juncture the extent to which your claims containing such modifiers will be screened prior to payment. Since this new effort is part of their "audit" process, and audits typically take only a portion of the targeted claims for review purposes, one may presume that not every claim with a -59 modifier will be scrutinized. Regardless of the scope of the Anthem audit, this is just one more example of the pre-payment screening movement beginning to spread.

The Way Around

You can be assured that your business partners at Anesthesia Business Consultants are not only aware of these recent efforts to hold up payments, we are working on ways to mitigate their effect on your bottom line. We understand that a steady flow of expected funds is of paramount interest to our clients, and we have already found ways to go around the obstacles placed in our path. Some of these strategies involve internal adjustments that compliantly ease the restrictions to payment, while others may involve obtaining a bit more cooperation from our partners.

One of the ways you may be asked to help is to consistently ensure optimal documentation of your post-operative pain service. As you already know, the anesthesia record or supplemental medical record (e.g., pain progress note) must contain the following documentation, at a minimum:

• WHAT? What service was performed? For example, "Placed epidural."
• WHO? You are required to indicate the specific provider who placed the block. Not every acute pain block is performed by the clinician(s) providing the anesthesia for the case. If a care team was involved, the coder needs to know which one of the providers placed the block. So, again, you need to specify who placed the block.
• WHOSE? At whose direction did you perform the block? Often, upon audit, a payer may hesitate to reimburse you for the post-operative pain service unless there is a specific notation that it was performed at the request of the surgeon. So, at a minimum, you will need to denote "at surgeon's request" within your block note. In some jurisdictions, payers are wanting to see a progress note from the surgeon justifying the referral of the pain service to the anesthesia provider.
• WHERE? You must specify the anatomical location of the block. If it was an epidural, was it cervical, thoracic, lumbar or sacral? At which spinal level was it placed? If it was a nerve block, the specific nerve(s) implicated must be documented.
• WHICH? We need to know which mode of pain blockade was used: continuous catheter or single-shot injection.
• WHEN? As you will remember, the American Medical Association (AMA) ruled a few years ago that you can bill anesthesia time during which you are placing a separately billed acute pain block as long as the placement occurs after induction of the primary anesthetic and before emergence. It would therefore be beneficial for you to indicate BOTH the start AND stop time of these placements, as well as the induction time. Many of you document via an EMR, so typically some or all of these times will be captured automatically. 
• WHY? Perhaps most importantly, it is critical that you indicate on the record that the epidural, spinal or peripheral nerve block was performed specifically for the purpose of addressing post-operative pain. In other words, there must be no question in the minds of our coders or the payer's auditors that the block you're additionally billing was used for post-operative pain, rather than as the primary anesthetic or to augment the primary anesthetic. Therefore, we require you write "for post-op pain" within your block note if it meets that criterion.

In addition to the above minimum documentation requirements, we may ask some of you to provide additional forms, records or affirmations. Some states and payers require more information to support these additional claims, so your cooperation in this area when requested by your account representative will prove invaluable. We will of course continue working on our end to minimize any delays in payment these carriers would otherwise be creating through the pre-screening process. When necessary and where warranted, our AR representatives will issue appropriate appeals. It will take a team effort on the part of all of us to find ways around these new obstacles.

The Road Ahead

There is no doubt that a continuing assortment of hindrances and hurdles will be placed in our path as payers find new ways to cut expenditures. When two or three major carriers institute tactics designed to delay automatic adjudication of claims, it may not be long before others catch on and follow suit. This does not mean, however, that we must allow ourselves to be taken for a ride—a bumpy one at that. There remain reasons to be hopeful. For example:

1. Your business partners at ABC are well-equipped to nimbly respond to each new challenge faced by our industry. We have a long history of successfully addressing changes in payer policies to the benefit of our clients. We mean to carry on that tradition.
2. There are certain things that state anesthesia societies and our national society can do to persuade governments when insurance companies go too far in restricting fair remuneration for services rendered. For example, Illinois' legislature recently passed a unanimous bill outlawing unwarranted delays in payments relative to state Medicaid products. If they don't pay legitimate claims within 30 days, the companies face a penalty. This one law proves that effective lobbying against unfair payer tactics can work.
3. As to this most recent matter—the prepayment screening of ancillary services—we believe our clients will emerge relatively unscathed. Again, this will depend, at least in part, on the quality and consistency of your documentation. 

Rather than creating concern, this latest move by a few payers to scrutinize certain claims actually creates an opportunity for all of us to redouble our efforts to strive for excellence. As long as we do that, the road ahead still looks bright.