eAlerts
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Robert Johnson, MBA
Principal, Enhance Healthcare Consulting, Aventura, FLRobert Stiefel, MD
Co-Founder and Principal, Enhance Healthcare Consulting, Aventura, FL -
Coding Corner: Important Role Of CPT Surgical Codes
Jody Locke, Vice President
Anesthesia Business Consultants, LLC
Many anesthesiologists believe that the ASA codes developed by the American Society of Anesthesiologists in the 1970s are the only codes they need to know in order to bill appropriately for the services they perform. Even though it is true that more than 75% of insurance claims for anesthesia charges are now submitted using ASA codes, it would be a very serious mistake to ignore the important role CPT surgical codes continue to play in correct coding. Certified coders understand that the only accurate way to determine the appropriate ASA code is via the ASA Cross-Walk. They understand that you can go from the specific to the general, but not the other way around. Ignoring the Cross-Walk can lead to significant under- and over billing. The following are just a few examples of the subtle interplay between the procedure-specific CPT codes and the more generalized ASA codes. Each example highlights the kind of confusion that can be created by referring only to the ASA Relative Value Guide.
Consider an inguinal hernia repair. The typical inguinal hernia is coded with CPT code 49505, which crosswalks to ASA code 00830 with a basic value of 4 units. A laparoscopic hernia repair, by contrast, should be coded with CPT code 49650, which corresponds to ASA code 00840 with a basic value of 6 units. Our experience is that an inexperienced coder or a physician coding only from the ASA Relative Value Guide would miss the subtle distinction more often than he or she would catch it and lose 2 billable units each time as a result.
p>Another very common area of confusion relates to the distinction between the two most common codes for abdominal procedures, ASA code 00790 with a base value of 7 units and ASA code 00840 worth 6. Because much of the large intestine lies in the lower abdomen there is a tendency to code any procedure on the cecum or large intestine with code 00840, but this would be a costly mistake. A sigmoid resection is properly coded with CPT code 44141, which is mapped to ASA code 00790 in the ASA Cross-walk. If the only point of reference were the ASA guide the result would be a loss of one billable unit per procedure.
Sometimes the confusion is related to a slightly different aspect of coding. When there are multiple code options, as occurs when multiple surgical procedures are performed during a case correct coding guidelines involve picking the code with the highest relative value. To code a case involving an EGD and a bronchoscopy the coder must consider the code for the EGD (43235) and the code for the bronchoscopy (31622). Since the first corresponds to ASA code 00740 with a base of 5 units and the second to code 00520 with a base of 6 units, the correct code for the case is 00520 and not 00740 even though it might seem that the EGD is the more significant component of the service.
These are just a few examples of the many discrepancies routinely identified by the ABC coding department when client physicians do their own coding based exclusively on the ASA Relative Value Guide. As the old saying goes, anyone that believes anesthesia billing is easy is either a terrible biller or a terrible liar. If you want optimum results let professionals make appropriate determinations using appropriate tools.
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Compliance Corner: 3 Cost-Effective Compliance Tips To Jump Start Your Compliance Efforts
Abby Pendleton
Wachler & Associates, P.C.As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers.
TIP #1 - OBTAIN BILLING AND DOCUMENTATION POLICIES:
A vital component of any effective compliance program for an anesthesia or pain practice is to ensure that the practice is apprised of all major third party payor billing, coding and documentation policies and guidelines applicable to the services provided by the practice (i.e., anesthesia and pain services). The practice should be mindful that different payors often have different policies and thus compliance with one payor's policy does not necessarily equate to compliance with another's policy. In addition to being aware of all applicable policies, the practice must also understand these policies.
In order to make sure the practice is obtaining necessary billing and documentation rules and guidelines, the practice should designate an individual who is responsible for (1) determining which third party payors have published policies and guidelines (this can be accomplished by making telephone calls and researching websites); (2) creating a list of the payors (with applicable websites) that have policies and guidelines and keeping the list updated; and (3) obtaining the available information. The Medicare Carriers all have websites and many have email services that are easy to register with.
TIP #2 - CREATE A DISTRIBUTION SYSTEM:
Once the practice is obtaining necessary billing and documentation information, the information must be appropriately disseminated to physicians. As the policies may contain requirements regarding documentation and frequency limitations in addition to coding issues, the physicians and providers in the practice should be included in the distribution. Many physicians believe that they do not need to review the materials as long as their billing company/administrative staff is aware of the policies. Physicians must understand that they are personally responsible for services billed under their numbers. Moreover, that the payor policies often contain information necessary for the physician such as specific documentation elements that must be contained in the record to support billing of a service. In addition to the potential audit and overpayment exposure that exists for failing to comply with payor policies and guidelines, physicians should be aware that certain patterns can lead to the physician being de-participated from a payor program.
In order to make sure that the practice has an effective distribution process in place, the practice should designate an individual responsible for (1) creating a distribution process and (2) ensuring that the process is carried out. The distribution process can be handled in a number of ways including having a person responsible for initially reviewing all materials and copying or highlighting pertinent portions to be distributed via email, mailboxes or in another manner. The person responsible may also consider creating a distribution spreadsheet that is marked off when materials are distributed. This will serve as a double-check to ensure that all individuals who need the information were provided the information.
TIP #3 - INCLUDE EDUCATION IN REGULARLY SCHEDULED MEETINGS:
As a compliment to TIPS 1 and 2, the practice should make compliance education a component in regularly scheduled Board or other corporate meetings. For example, when a new policy is published by Medicare that impacts the practice (e.g., a policy on anesthesia for endoscopy cases, etc.) , the policy should be discussed at the meeting to ensure that everyone has received the information and understands the information. If there are no new policies to discuss, the allotted time for education can be used to provide refresher education on other issues. For example, the definition of anesthesia time could be discussed to ensure everyone is tracking and documenting time appropriately. The practice should also document these educational efforts. This can be accomplished by drafting simple meeting minutes that reflect that compliance education on a particular topic took place. It is important to document that the education occurred. The documentation does not have to include all of the substance of the discussions.
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Anesthesia Customer Service
Jody Locke
Vice President Anesthesia Business Consultants, LLCIf you believe that clinical excellence will ensure your continued success and prosperity as anesthesiologists or CRNAs, you are in for a rude awakening. A growing body of objective evidence clearly indicates that in today's competitive healthcare market a solid commitment to service excellence is a far more critical determinant of the longevity of an anesthesia practice. The problem for the typical anesthesiologist or CRNA who was trained to anticipate the physiologic responses of surgery and a complicated array of pharmacological options and respond with an appropriate alternative in a matter of seconds is that the economic forces affecting the future of all medical specialties do not respond to the same kinds of quick fixes and historical solutions as does the human anatomy. The problem-solving skills that were so carefully learned during residency have little relevance outside the operating room. It has become one of the great ironies of modern medicine that experienced clinicians who can make life or death decisions in a matter of seconds become hopelessly paralyzed in the face of today's economic realities.
Every anesthesiologist and CRNA understands the value of good customer service when dining out with the family or getting the car serviced. We can all appreciate the value of a promise that is consistent with reality. Who does not appreciate the employee that goes out of his way to deliver an unexpected service? We all understand why the waiter comes back to the table after the food has been served at a good restaurant to ensure that expectations have been met; it clearly demonstrates the restaurant's commitment to satisfying the customer so he or she will not only come back but rave about the experience to others.
Perhaps the real problem in anesthesia is that patients are not seen as customers, but they are. So too are the surgeons who bring them to the facility, the administration that makes it all possible and the various other professionals without whose diligence and persistence operating rooms would not run at all. To the extent that the focus of one's efforts is viewed as a patient the interaction is limited to a dispassionate exercise in clinical problem solving, but when these same patients become customers then their hopes, fears, expectations and requirements all become part of a much more complicated and dynamic equation.
The situation is further complicated by the variety of customers and the diversity of their expectations and requirements. While the goals and objectives of anesthesia administration can be clearly defined, it is not so easy to reconcile the often conflicting expectations of patients, surgeons, operating room staff and hospital administrators. Sorting them all out is a much less objective process; in fact, it can be highly subjective and unpredictable. It is all too easy to suggest that anesthesia providers are not good at it because this was not part of their training. Anyone who can get an "A" in organic chemistry can figure this out.
Market competition is based on the premise that customers have options that they will seek service providers who they believe are most committed to meeting their specific needs and expectations. This is the part of the equation that does not fit the clinical mindset and training. Clinicians want to believe they do what is necessary and appropriate because it is the right thing to do, not because it will win them points on a customer satisfaction survey. Just as college professors must now prepare their lesson plans with an eye to the evaluations their students will give them, so too are anesthesia providers increasingly being evaluated on their ability to communicate effectively and allay their patient's anxiety about surviving surgery.
The clinical algorithm does not allow for contradictions and inconsistencies; the medical scientist does not view the world through the same lens as the social scientist. Each anesthetic experience must be neatly packaged like a five act play. While the experience is designed to anticipate the almost limitless number of options that are created by diverse patient populations, thousands of surgical options and different operative conditions it is not a free-form improvisation. Most options and variations on the theme are carefully scripted and the product of experience. Ultimately, all the data and indicators should be reconcilable and result in a clear course of action. The specialty understands that its practitioners must strive for and embody ability, availability and affability except when these qualities conflict or do not seem to fit the circumstances. There appears to be an unwritten rule that if in doubt stick to ability and hope that the other two will eventually sort themselves out. This is analogous to the age-old advice that it is always easier to ask for forgiveness than permission.
Ironically, the specialty's greatest asset is also its most critical liability. The clinician's ability to be so focused and disciplined in the operating room is his greatest liability outside the operating room where problems are not solved in a matter of seconds, nor even by the application of a unilateral solution. There is no doubt that customer service represents a different paradigm. Customers must be enrolled in the promise of good service. Communication lies at the core of their experience and satisfaction. The good news is that figuring it out requires much less training and experience than giving anesthesia; it just requires a willingness and commitment to accept its relevance and importance and to practice it until it becomes second nature.
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Who Is Really Managing Your Practice?
Jerry Ippolito
Vice President & PrincipalOnce again I've been flattered by the request to write an article for the Communiqué. On this occasion the question was posed, "what do you see as most challenging issues to anesthesiology practices in the area of perioperative services?" One might readily respond reimbursement, however I believe that is a prevailing challenge to the healthcare industry overall and not unique to anesthesia. Others might suggest low OR and anesthesiology utilization. In my consulting practice I have the opportunity to work with fifteen to twenty hospitals and anesthesiology practices each year. The most prevailing and challenging issue encountered for anesthesiology, and the question I'm posed most often by anesthesiologists is, "should we have a services agreement and should we be involved in the schedule?". Some anesthesia groups, and physicians in general, still maintain an old-school outlook of being independent practitioners on a voluntary medical staff and functioning independently of the hospital. In other instances, even where there is an exclusive contract between a hospital and anesthesia group, expectations are not clearly defined. Yet in additional instances, anesthesiologists will suggest to me, "Why would I want to participate in managing the schedule? - Why would I want that headache?" My response to these issues is that if a services agreement and expectations are not in place (even where there is no exclusive contract) you, anesthesia, will never be able to meet customer expectations. Keep in mind that anesthesia's customers are numerous including at least surgeons, hospital administration, the director of surgical services, and oh yea, the patient (not even yet addressing GI; OB; radiology; Cysto; etc). Also keep in mind that the perception is always that, "The OR would run better if anesthesia stepped up to the plate." If expectations are not defined and anesthesiology is not proactively participating in schedule planning and administration in collaboration with OR management, then anesthesiology can only be reactive and subject to the decisions of OR management; this frequently results in dissatisfaction and conflict. If expectations are not in place and anesthesia is not involved in the schedule, then "YOU ARE NOT IN CONTROL OF YOUR BUSINESS."
If anesthesia is to successfully step up to the plate and fulfill expectations there needs to be reasonable definition of expectations. (Where are the plates located; Do you mean a plate or a bowl? How big a plate do you want ? When do we serve meals?). No group or body or person can successfully deliver services and fulfill expectations on an ongoing basis without definition and direction. To this point, and for anesthesiology and perioperative services, development of expectations should at least include definition of:
- Numbers of rooms staffed by hour of day and day of week;
- Call coverage (in v. out-of-house; anesthesiologist or CRNA; etc);
- What services are required by obstetrics and what is considered timely delivery of services;
- Development and delivery of effective and efficient pre-admission screening services;
- Case/patient familiarity prior to day of surgery;
- What services are provided to peripheral sites and when (endo; radiology; response to codes; etc);
- What is the role anesthesia plays in schedule planning and administration?
- How are the requested/expected anesthesia services compensated for if there is insufficient revenue from anesthesia professional fees?
Anesthesia's proactive involvement in schedule planning and administration is most paramount to the successful delivery/fulfillment of expectations. When anesthesia is not involved in the schedule, then anesthesia is continuously in a reactive mode; communication breaks down; expectations remain unfulfilled; dispute results even with best intentions for success.
A formalized charge anesthesiologist or board-runner function needs to be considered for every OR program each weekday, during normally active working hours (and on weekends where there is an active elective schedule). Charge anesthesiologist function and responsibilities (i.e. expectations) should be uniformly developed and one lead anesthesiologist should be assigned. The lead charge anesthesiologist position must be assumed by an individual with strong leadership, administrative and organizational skills and personal attributes. The lead anesthesiologist should be given responsibility for organizing all facets of the position; establishing protocols with nursing, OR management, the OR committee and training the others assigned as back-up charge anesthesiologists in the established protocols. In most programs, the back-up charge anesthesiologist position generally rotates among remaining anesthesiologists. Frequently the daily responsibility is assigned to the physician on call as it may have already been determined that the oncall anesthesiologist serves in a "light-duty" capacity. Ideally, the daily charge anesthesiologist position should be limited to as few individuals as possible (although typically no one person relishes this position). Regardless of the number of individuals assigned to the function, it is critical that decision making, policy/procedure enforcement and OR scheduling/operations support be maintained in a consistent manner.
Individuals assigned to the daily charge position should have their direct care responsibilities minimized as greatly as possible. For practices maintaining an MD-Direct Care model, where anesthesiologists are in rooms and directly administering anesthesia to patients, anesthesiologists assigned the charge position should make efforts to schedule themselves in rooms with shorter, lower complexity cases and to patients of lower acuity levels. For practices using the Care Team model of physicians medically directing CRNAs, in addition to supervising assigned CRNA cases of routine complexity, the charge anesthesiologist can provide support to PACU, Pre-admission Screening, the holding area, and emergency case coverage. Whenever possible no more that two CRNAs should be under the medical direction of the charge anesthesiologist.
The most critical role of the charge anesthesiologist is to work with nursing in management and maintenance of the schedule; optimize case throughput; and to organize, from an anesthesiology coverage standpoint, all add-ons/changes to the schedule. The charge anesthesiologist is also responsible for reviewing the following day's schedule and making anesthesiology assignments for following day's schedules. In collaboration with the charge nurse, the charge anesthesiologist should be reviewing and assisting to coordinate OR scheduling as far out as 72 hours prior to time of surgery. The charge anesthesiologist functions, in very general terms, as the "go to person for anesthesiology", however the function is proactive in participation of schedule planning and administration rather than reactive to daily and immediate needs of the schedule.
The charge CRNA should round throughout the OR as frequently as possibly and be knowledgeable regarding status of individual cases and rooms. In practices without CRNAs, the charge anesthesiologist should circulate throughout the OR as frequently as possible/ allowable based on direct care responsibilities. The OR charge nurse should maintain this practice regardless of anesthesiology delivery model. Together, the charge anesthesiologist and charge nurse maintain responsibility for expediting the day's activities through their familiarity with each room's status and determining when to call following patients to holding or OR. The burden of rounding in the OR and maintaining effective communication with the charge anesthesiologist is more greatly assumed by OR charge nurses in practices using the physician direct care model. The function of being knowledgeable of each case and room status and maintaining communication between nursing and anesthesiology remains the same regardless of anesthesiology model and in the MD-direct model the need to proactively plan the schedule in advance is even more paramount in order to minimize anesthesiologists' distraction from direct patient care on any given day. Zone phones provide a reliable means of communicating with a charge anesthesiologist when that individual must leave the OR proper to attend to responsibilities in peripheral sites.
Case assignments for following day's cases are typically made by the charge anesthesiologist enabling anesthesiologists and CRNAs to familiarize themselves with the following day's schedule; patients' conditions and case requirements; facilitate general planning of following day's activities. Specific protocols regarding how assignments are to be made and the time they will be made should be established and followed by all charge anesthesiologists. Indeed, some may correctly contest that being too specific in delineating expectations will also lead to unfilled expectations and dispute. OR management, administration, surgeons and anesthesiology must come to reasonable compromise as to definition, direction, expectations, and responsibilities. Ignoring or evading the need for expectations development and anesthesiology's participation in schedule planning and administration only "Puts Someone Else in Control of Your Anesthesiology Practice."
