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A Self-Diagnostic for High-Performing Anesthesia Group Leaders

Although the editor, bless her heart, steadfastly refused to let me have a sneak, pre-publication peek at the other articles that appear alongside this one, my educated guess is that each of them purports to give you answers.I know that's why you usually read Communiqué. In fact, nearly every one of the hundreds of other articles that I've written ...
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2018 CPT Coding and Key Reimbursement Changes Pain Management and Anesthesia

• The 2018 CPT edition includes 170 new CPT codes, 60 revised codes and 82 deleted codes along with two new modifiers. It is important to understand the changes and what should be documented to support the utilization of these codes.• The majority of the changes for 2018 were new CPT codes added to the Surgery section, Pathology/Laboratory section ...
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Strengthening Your Anesthesiology Group

“Most people choose unhappiness over uncertainty.” — Timothy Ferris Anesthesiology groups are facing unprecedented challenges. How will the Affordable Care Act affect them? What will happen when ACOs get up and running? Should our group sell to an investment group? Should we pursue hospital employment? These are truly uncertain times. Unfortunately many groups are in a reactive mode, struggling with how to deal with threats and opportunities in the marketplace. This is often because their governance and management processes were formed at a time when there were fewer stressors and challenges. Some group are sprinting towards relationships that appear to offer financial reward and some level of security, but at the same time have the potential to severely limit the group’s and the physician’s autonomy. While there are situations where employment may be appropriate, many groups that pursue this course are “choosing unhappiness over uncertainty.” If your group intends to remain...
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Student Training Programs May Pose Significant Liability Exposure to Anesthesiologists

Anesthesiologists are frequently requested to participate in student training programs for emergency medical technicians (EMTs)1, student nurse anesthetists (SRNAs), medical residents and students and respiratory therapists to provide training and supervision for intubation proficiency and airway maintenance. While most professional liability carriers provide coverage for participating in these student training programs, the following case summary underscores the significant liability exposures that can arise. A 20 year old female, 5’4”, 38.5 kg, with a medical history significant for kidney removal, duodenal obstruction and persistent vomiting for 4 days presented for Roux-en-Y gastric bypass and appendectomy. A nasogastric (NG) tube had been placed on the day of the procedure, but the NG tube had been “sneezed out” approximately two hours prior to the procedure. The surgeon was aware the NG had come out; however, that information was never conveyed to anesthesia. The anesthesia group had a contract with the county emergency medical services...
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Successfully Competing In Anesthesia Services Today

Recently I had the pleasure of speaking with anesthesia residents and faculty at a well-known progressive academic anesthesiology department. Opportunities like this are among the high points of my professional life because I invariably know more when I leave these presentations than when I arrive. This time was no different. My recent professional focus has been on working with hospitals and health systems to identify workflow enhancements and quality improvement initiatives to streamline care delivery and deliver greater total value. On a more theoretical level, I have been identifying and developing novel ways to produce comparable or better perioperative medical care in terms of price, quality, and service by using nontraditional processes or clinicians in nontraditional ways. With few exceptions, however, these latter efforts fall mainly into what one would call product development—showing promise but not yet ready for prime time. The topic, then, for this visit was the role of...
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Is Big Better?

  I am an anesthesiologist. The leadership of my small group of 15 physicians has been negotiating a merger with the large group in a nearby city. They have made some compelling arguments for the strategic advantages of an affiliation with a larger entity. But as logical as the rationale for merging is, so are the concerns and the questions raised by detractors. It is just not clear that all the disruption of closing out our current entity and transitioning to employment status with the big group will result in a more favorable situation for us as individuals or even as a division of the new entity. I personally worry about losing control of my practice and the clinical autonomy that attracted me to this practice in the first place. The fact is that I am still unsure how I will vote when we all get together to make a final...
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Why You Need a Quality Management Program

  The Anesthesia Quality Institute (AQI) is a non-profit corporation created to improve outcomes in anesthesia, based on aggregating, analyzing and reporting electronic data. Over the past three years AQI has recruited more than 220 anesthesia practices, from 44 states, to contribute data to the National Anesthesia Clinical Outcomes Registry (NACOR). The aggregate data has provided a unique and valuable perspective on the specialty of anesthesiology: What we do, what we know, and how we do it. At the same time, a picture is emerging of the other side of our national practice: What we don’t know and what we don’t do. The widest performance gap in anesthesia today is our collective lack of insight regarding outcomes of the care we provide. Even among the participating groups in NACOR—a self-selected ‘choir’ of early adapters—fewer than 1 in 5 have the infrastructure to recognize and respond to the following event: Mrs. Smith,...
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Compliance Corner: Reporting Post-Operative Pain Management Procedures in 2013

Christopher Ryan, Esq. Giarmarco, Mullins & Horton, P.C., Troy, MI Neda M. Ryan, Esq. Clark Hill, PLC, Birmingham, MI Reporting post-operative pain management procedures often gives rise to questions, especially toward the beginning of the new year when the Centers for Medicare and Medicaid Services (CMS) issues its National Correct Coding Initiative (NCCI) edits. Historically, epidurals and blocks that are placed pre-operatively for the purpose of managing post-operative pain have been, and still are, separately reportable and not bundled into the anesthesia service itself. The exception to this general rule is when the epidural or block is the anesthetic itself. While CMS has not called for significant changes in 2013, anesthesia providers should, nevertheless, be aware of new post-operative pain management coding changes taking effect January 1, 2013. NCCI Edits   The NCCI edits for 2013 provide, in part, that certain post-operative pain management procedures may only be separately reportable with...
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Three Common Issues

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...
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Update on the Company Model and Other Schemes—OIG Issues Advisory Opinion

  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...
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Update on the Company Model and Other Schemes—OIG Issues Advisory Opinion

[Author’s Note: A version of this article originally appeared in the August 2012 issue of Anesthesiology News.] 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...
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The Company Model

    The most important event of the year to date, for anesthesiologists and for everyone involved in health care in any way, was of course the Supreme Court decision upholding the Affordable Care Act. Also of great consequence to the anesthesia community was the “company model” Advisory Opinion issued by the Office of the Inspector General on June 1, 2012. Mark Weiss, Esq., whose name is familiar to many readers and for whose frequent contributions to the Communique we are very grateful, describes the company model and the management fee model “other schemes” and explains why these are illegal if they represent payment to the ambulatory surgical center for giving physicians access to Medicare patients. Mr. Weiss’s article adds further clarity by placing the OIG’s June opinion in the context of earlier determinations. A set of other frequent contributors, Abby Pendleton, Esq., Carey Kalmowitz, Esq. and Adrienne Dresevic, Esq., all...
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A Survey of State Prompt Pay Laws, Part I

  Many states have laws or regulations in place that require health insurers in the state to reimburse claims within a certain timeframe or face penalties, oftentimes in the form of interest applied to the amount of the claim. Such laws or regulations are typically called “Prompt Pay” laws or “Clean Claim.” While each state or, sometimes, insurer, defines the requirements for a claim to be a “clean claim,” generally, a “clean claim” is a claim that has all of the information an insurer needs to either pay or deny the claim. A “non-clean claim” is a claim that requires additional information or documentation to make it clean. Each state sets forth the timeframes in which insurers have to reimburse a clean claim. Absent certain exceptions (e.g., instances of suspected fraudulent activity, contractual provisions setting forth alternative timeframes, etc.), failure to adhere to the timeframes results in penalties oftentimes in the form...
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Clarifying TEE ’s Coding and Documentation Requirements (CPT 93312-93318)

  Several clients have inquired as to the documentation and correct coding and billing for Transesophageal Echocardiography (TEE) services. A TEE is a special diagnostic tool, which may be used by properly trained physicians (i.e., anesthesiologists, cardiologists) to benefit patient care. A separately reported TEE may be performed for monitoring and/or diagnostic purposes. However, many payers will only reimburse diagnostic studies.   For example, to establish conditions such as myocardial ischemia or cardiac valve disorders, the anesthesiologist will be utilizing the transesophageal echo for diagnostic purposes. In this case, when the anesthesiologist has the additional certification or documented training in residency, and is privileged by the hospital to do the complete procedure, the anesthesiologist can and should bill separately for the TEE in addition to the anesthesia. The correct CPT code for the complete procedure is 93312. When you bill for both the anesthesia and the TEE, the coder must append...
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Anesthesia Quality Databases

The focus on quality outcomes in healthcare has been long in coming. As the cost of health care continues to rise faster than the cost of living, the nation finds itself facing a dilemma. Perhaps a free market approach to healthcare is not the best approach after all. Economic incentives and ground breaking research have clearly provided significant advances in some areas, but what has been their impact on cost? As diverse and independent as the specialty of anesthesiology is, its practitioners have challenged the leadership to take the lead in finding ways to provide quality care more consistently so that anesthesia is not a contributor to the cost of healthcare but a regulator of spending. While virtually all anesthesiologists and CRNAs have now become familiar with the current requirements of the Physician Quality Reporting System (PQRS), this is just one example of a public approach to ensuring consistency based on...
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Protect the Privacy and Security of Your Anesthesia Patients' Electronic HIPAA Information

Many “Covered Entities” within the meaning of the privacy and security provisions of the Health Insurance and Portability Act of 1996 (HIPAA) are managing more and more of their patient information electronically.  Indeed, not moving to electronic health records (EHRs) may cost physicians a percentage of their Medicare remittances—or at least the loss of a potential bonus of up to $44,000—under the EHR Incentive Program, as discussed in our last several Alerts.Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible.  The key word in the preceding sentence is “unsecured.”  The recently finalized HIPAA regulations on Breach Notification impose...
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Proposed Changes for Anesthesiologists and Pain Physicians Who Report Measures to the PQRS

Anesthesiologists and pain physicians who have been receiving bonuses for participating in Medicare’s Physician Quality Reporting System (PQRS) should continue to do what they have been doing.  The proposed Fee Schedule rule (NPRM) for 2013 does not contain any new requirements affecting those who are already successfully participating, as we noted summarily in last week’s Alert.For physicians who have yet to earn a PQRS incentive payment, the NPRM would make reporting easier in future years.  This is important, because failure to report PQRS measures will result in financial penalties beginning in 2015—based on reporting in 2013.  The amount of the payment adjustment, positive or negative, will be as follows: 2013+0.5% 2014+0.5% 2015-1.5% 2016 on-2.0% CMS has stated that one of its major goals in developing its proposed changes was to increase participation to 50% of eligible providers in 2015.  In 2010, the overall level of participation was only 24 percent.  (“2010 Reporting Experience, Including Trends (2007-2011): Physician...
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What does Medicare's 3-Day Payment Rule Mean for Anesthesia and Pain Practices?

Another Medicare compliance deadline approaches, and it has attracted a fair amount of attention.  The good news is that it will apply to few pain physicians and even fewer anesthesiologists.  Sometimes it is necessary to explain a new rule or requirement just so that our readers know not to worry.  This is one of those times.By July 1, 2012, those physicians and facilities that are affected are expected to be in compliance with the “3-day payment policy.” The 3-day payment window applies to certain outpatient services provided by hospitals and hospitals’ wholly owned or wholly operated entities, including physician practices.The policy has applied to diagnostic services and related non-diagnostic services since 1998.  The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 broadened the definition of related non-diagnostic services that are subject to the payment window to include any non-diagnostic service that is clinically related to...
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Managing Compensation for Anesthesiologists, CRNAs and AAs

  A moderated discussion of compensation strategies at last week’s MGMA-ACMPE AAA meeting showed a good deal of flexibility in allowing anesthesiologists to job-share or otherwise to reduce their hours. The groups represented at the discussion were also creative in compensating members for business development and administrative activities. If case loads decline substantially, layoffs may occur, although they are the least favorite option.Along with more than 300 other MGMA-ACMPE Anesthesia Administration Assembly (AAA) members and exhibitors, we participated in the annual AAA meeting in Scottsdale last week.  One breakout session discussion group in particular was so informative that we obtained permission to bring a summary to our readers.About 60 individuals attended the discussion of compensation strategies moderated by Stephen E. Comess, Executive Director, United Anesthesia Services, P.C.  Mr. Comess got the ball rolling on responses to twelve prepared compensation management scenario questions by giving each member of the audience a playing...
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ABC Works With Epic Anesthesia to Establish Automated Electronic Transfer of Anesthesia Records

Anesthesia Business Consultants (ABC) keeps a keen eye on the continued proliferation of electronic medical record (EMR) technology.  It is not enough to adopt the latest technology, ABC investigates the latest technological advancements in EMR, carefully testing new systems to ensure their compatibility with our renowned OneSourceAnesthesia platform, and working with leading-edge software providers.  Our goal:  to facilitate a smooth transition from paper to electronic billing of anesthesia services.  ABC strategically considers each upgrade from both a technological and functional update—in an effort to provide clients an unparalleled level of service. OneSourceAnesthesia Successfully Integrates EMR with Epic Anesthesia ABC is pleased to announce that we have successfully interfaced with Epic Anesthesia.  ABC worked with Orange Regional Medical Center and its Epic project team on a repeatable approach for electronic professional billing at Orange Regional Medical Center, located in Orange, New York.  The records and billing information, when combined with the automated...
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