Preparation in the Era of COVID: How Anesthesia Will Need to Adapt
Summary
Anesthesia groups are moving out of their comfort zones during the COVID-19 crisis, with many taking on new models of care. The changes that come with new priorities may be moving more rapidly than the provider's ability to keep up. In the midst of pandemic and pandemonium, preparation will be the key.
There are five phases of an anesthetic: preparation, induction, maintenance, emergence and recovery. It is the standard clinical model that has served as the basis for training today's anesthesia providers. Over the course of their instruction, anesthesia providers are drilled in clinical decision trees, which is what makes them such effective clinicians in the operating room. With COVID-19 patients, we now see a paradigm shift. Whether patients are being anesthetized in the operating room or treated in the ICU, the coronavirus makes for a much more complicated and challenging clinical experience. One can argue about which of the five phases is the most critical to a successful outcome, but clearly the preparation phase is essential. It is the very unpredictability of COVID-19 complications that compels anesthesia providers to become assiduous students of this virus.
Preparing for Extra Payment
Many practices are experiencing a contraction in the number of anesthesia cases they normally perform due to a restriction on non-essential surgeries. Instead, a good number of anesthesia providers are being re-tasked to performing non-OR cases, such as critical care, emergency intubations and stand-alone invasive line placements—services which yield much less in reimbursement than the typical anesthesia case. During this time when many of you are experiencing a financial hit, it should bring some encouragement to know that there are ways to enhance your potential for higher payment.
A recent survey of ABC clients demonstrates the unique challenges associated with intubating COVID-19 patients. Every practice with a population of these patients is reporting a marked increase in the number of emergency intubations. Not only must every precaution be taken to ensure that the provider does not become infected, but the very nature of this disease—with its potential for respiratory complications—means that these will be anything but typical intubations. Most clients agree that these conditions meet the criteria for an additional payment, which can be effectuated by our billing staff appending the -22 modifier to the emergency intubation code, 31500. This modifier signals to the payer that the provider expended extra time and effort due to the unusual difficulty or circumstances involved in the patient procedure. Depending on the health plan, such cases may yield an average increase in reimbursement of 20% or more.
Even routine anesthetics may involve additional time due to the absence of PACU personnel who are attending to COVID-19 patients. Average recovery wait times may be 30 minutes or more. The good news is the additional time should be recognized in the payment calculation, so long as the reason for the inordinate time spent by the anesthesia provider in the PACU (or wherever recovery takes place) is sufficiently documented on the record.
Although there is much discussion about insurance coverage during this national health emergency, there is general agreement that Medicare (and perhaps other payers) will show a greater willingness to err on the side of payment than recalcitrance. Nevertheless, you must prepare to meet their documentation requirements for these potential payment enhancements. For example, one Medicare jurisdiction in the Midwest published the following criteria for supporting use of the -22 modifier:
When the modifier 22 is used, two separate documents will be required to support the claim:
- An operative report; and
- A separate statement indicating how the service differs from the usual
When developing a separate statement avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty.
Therefore, be prepared to support your request for additional reimbursement on a consistent basis.
Critical Care: How Prepared Are You?
The ICU is a venue in which anesthesia providers are being asked for assistance. Anesthesia providers are being called to assist the ICU physicians in the management of acutely ill patients. While anesthesia providers have experience and expertise in the securing of complicated airways, there is much about the management of COVID-19 patients that poses special risks and challenges. In many ways, the recruiting of anesthesiologists and CRNAs to the ICU represents a logical clinical line extension, and yet it is a new venue for which most are inadequately prepared. In anticipation of what may be a critical role, our anesthesia clients should consider the following issues as they prepare themselves for this vital service.
The first question they should ask is, what role are we going to play? Are we going to assume responsibility for acutely ill COVID-19 patients such that we must now act as intensivists and bill for our services with ICU codes 99291 and 99292? As we have explained in previous e-Alerts, there are specific criteria that must be met for the submission of these codes. Specifically, the provider must document the acuity of the patient's status and the amount of time spent in the management of the case.
Preparing to Meet Any Challenge
In many hospitals, intensivists will continue to work up and manage patients with the expectation that the anesthesia providers will assist as proceduralists, intubating patients, inserting invasive monitoring lines and possibly performing a limited scope of other services. In such scenarios, providers should be diligent in their documentation and in the submission of their progress notes to the billing staff so as to ensure payment for all procedures performed.
The real challenge in this current environment is knowing what the anesthesia scope of responsibility will be. In most hospitals, it is difficult to predict when COVID-19 patients will present and in what numbers. Given this uncertainty, it is always best to prepare for the worst. Each practice should assess the potential impact of the virus on the local community and prepare a game plan. We urge providers to think of this on three levels: clinical coverage, documentation requirements and payment requirements.
Clinically, the practice should have identified which providers will be tapped to assist in the ICU and what the impact of deploying these providers to the ICU will be on the practice as a whole. Since the documentation of critical care services is not done on an anesthesia record, appropriate templates and forms should be identified, usually in conjunction with the billing staff. It may also be appropriate to negotiate financial support from the hospital, especially if coverage of the ICU will involve a call position.
If you are contemplating providing additional services to COVID-19 patients, it is an appropriate time to focus on the preparation phase of care. Try to assess as best you can the potential role you and your colleagues can play. Review protocols and documentation criteria. Make sure you have the necessary templates and skills. Your training will serve you well, but there is still much to learn.
As your billing and management partner, we are here to provide you with the guidance and support you will need during this extraordinary time. If you have questions, please reach out to your account executive or email us at info@anessthesiallc.com.