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Dear CMS: ASA Presents its Views on the 2010 Medicare Fee Schedule

August 31, 2009

Today is the deadline to file “comment” letters with CMS regarding the proposed Medicare Physician Fee Schedule for the calendar year 2010. The American Society of Anesthesiologists has made numerous points in its comment letter to the Centers for Medicare and Medicaid Services (CMS). Listed below are those of the most immediate importance to anesthesia practices:

  1. ASA objects strenuously to CMS’ proposal to prevent the 2008 teaching rule legislation from achieving its intended effect by restricting handoffs between attending anesthesiologists.
  2. On the other hand, CMS has appropriately proposed to maintain different criteria for concurrent supervision of residents by the teaching anesthesiologist and for concurrent supervision of student nurses by the teaching CRNA.
  3. CMS should postpone eliminating the consultation codes (CPT™ codes 99241-99245 and 99251-99255) and study the matter further.
  4. ASA encourages CMS to proceed with its proposal to implement the results of the Physician Practice Information Survey in updating the practice expense component of the fee schedule.
  5. CMS should add the Perioperative Temperature Management to the Physician Quality Reporting Initiative (PQRI), as proposed and expand the measures available for electronic health records.
  6. ASA urges CMS to include three new anesthesia measures in the 2010 PQRI and to support approaches to Congress to broaden the incentives for the use of e-prescribing systems.

What does all this mean to you?

Taking the points in order, first, academic anesthesiology programs have been anticipating that they will finally be able to bill Medicare 100% for each of two concurrent teaching cases, beginning on January 1, 2010. It has been a very sore point throughout the specialty that CMS has applied the medical direction rules to the teaching anesthesiologist’s supervision of residents and thus allowed only 50% of the payment amount for each case. Following the enactment of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, ASA’s long campaign for parity with teaching surgeons, who have always been able to collect the full fee for concurrent resident cases, seemed to have reached a successful conclusion. (The American Association of Nurse Anesthetists opposed the ASA’s efforts. If the AANA filed comments with CMS to that effect, such comments do not appear on the AANA’s website.)

It is therefore disappointing to ASA that CMS proposes to allow full payment in each concurrent resident case only if the same teaching anesthesiologist is present during all of the key or critical portions of the case. Handoffs from one attending to another, in other words, would only be acceptable during the relatively routine portions of an anesthesia procedure. Stating that it has no data on whether handoffs affect the quality of care, the Agency nevertheless intends to adopt regulations in effect requiring that the teaching anesthesiologist who supervises the resident during induction remain in the operating room suite throughout the case in case there are any other “critical” or “key” events. Public comments such as ASA’s may persuade CMS to change its mind. If CMS remains unconvinced, the regulations that go into effect on January 1, 2010 will thus restrict the ability of academic anesthesiologists either (1) to receive a full fee for many concurrent teaching cases or (2) to schedule cases so as to make optimal use of their time in the operating room.

  1. The proposed rule also addresses teaching CRNAs. In this regard ASA believes that CMS has interpreted the statute correctly; again, AANA’s views, if any, are not posted on its website.

    Teaching CRNAs who supervise student nurse anesthetists (SRNAs) in two concurrent cases will be paid at the “regular fee schedule rate.” If the teaching CRNA is being medically directed by an anesthesiologist, the actual time spent in each case should be reported. There is no change in this policy.

    If the teaching CRNA involved in two concurrent cases with SRNAs is not medically directed, beginning on January 1 – assuming that the proposal is finalized as is – payment will be based on the proportion of the total time for both cases that the CRNA spends in each case. The example given both by CMS and in ASA’s letter is the following: if a non-medically directed teaching CRNA is involved in two concurrent cases and spends 40 percent of his or her time in concurrent case #1 and 60 percent of his or her time in concurrent case #2, and the total anesthesia time in both cases is 3 hours (i.e., 180 minutes), Medicare will pay the regular fee schedule rate thus:

    1. Case #1: (Base units + (0.4 x 180/15)) x Anesthesia CF
    2. Case #2: (Base units + (0.6 x 180/15)) x Anesthesia CF
  2. CMS has indicated its intent to eliminate the codes for inpatient and outpatient consultations, CPT™ codes 99241-99245 and 99251-99255. Higher payment levels for consults were initially justified by documentation requirements that were more onerous than those applicable to other evaluation and management (visit) services, but according to CMS the requisite documentation is now similar across the board. ASA disagrees, on the grounds that obtaining the written request from the referring physician and sending back to a written report, as required in order to bill a consultation rather than a visit, still consumes more time and effort at least in the office setting without access to a shared hospital record. Many other specialties that perform consultation services have filed similar objections with CMS. Unless CMS changes its proposal, however, anesthesiologists and other physicians will need to use the office visit codes 99201-99215 and the initial hospital visit codes 99221-99223 instead of the consultation codes beginning on January 1, 2010.
  3. A relatively small part of the anesthesia conversion factor is based on estimated practice expenses. The practice expense data used for anesthesiology (and a majority of the other medical specialties) is more than ten years old. CMS now has before it the results of a major new survey conducted by the American Medical Association in 2007-2008. The Agency proposes to update its practice expense data with the new data, effective January 1, 2010. Using the AMA survey results, the practice-expense-per-hour value for anesthesiology will rise from $19.76 to $29.37. Not surprisingly, ASA is supportive.

CMS has proposed a number of other changes to the way in which fee schedule relative values are calculated, including site-of-service anomaly adjustments that would apparently result in payment cuts for pump/stim codes 62350, 62355, 62360, 62361, 62362, 62365, 63650 and 63685. Readers who are committed to understanding fully the fee schedule methodology are invited to study the 26-page ASA letter.

  1. ASA strongly encourages CMS to add Perioperative Temperature Management to the PQRI performance measures for 2010. If CMS does so, as seems likely, anesthesiology will have three PQRI measures and thus registry-based reporting will become at least a theoretical possibility. The ASA letter contains a detailed description of the new Anesthesia Quality Institute, whose mission is to develop a national anesthesiology data registry that will include a PQRI reporting mechanism. ASA also urges the Agency to recognize measures “relevant to anesthesiologists” on the list of measures available for reporting through an electronic health record-based system.
  2. Responding to CMS’ request for additional measures for the 2011 PQRI, ASA has asked the Agency to consider three new measures:
  3. Management of postoperative hypothermia;
  4. Prevention of post-operative nausea and vomiting – multimodal therapy, and
  5. Short half-life prophylactic antibiotic administered preoperatively is redosed within four hours after preoperative dose.

The full description of these proposed measures appears in Appendix A of the ASA letter.

ASA’s response to all of the Fee Schedule and PQRI proposals and requests for input published by CMS in the Federal Register on July 13, 2009 represent years of hard work and sophisticated analysis of the part of the Society’s officers, committee members and staff. We encourage you to read the letter if you are interested in greater detail. Although some of the changes discussed are almost certainly going to be in place on January 1, 2010, it is important to remember that the letter is a response to CMS proposals only. The final regulations for next year will be published in November. We will summarize them for you as soon as CMS makes them available.

As always, we welcome your feedback. If you have a question about this topic or if you have another topic you would like discussed, please let us know.

With best wishes,

Tony Mira
President and CEO