September 14, 2009

In our Alert dated August 24, 2009, we described Medicare’s system of national and local coverage determinations, policies that define the requirements for meeting the “medical necessity” standards for a large variety of medical procedures and services. This week we would like to elaborate on the content and importance of the articles and policies published by the Part B (physician services) Medicare Administrative Contractors (MACs), formerly known as your local Medicare carriers.

Interventional pain medicine continues to offer up riches to MAC medical directors searching for areas in which medical necessity may be unsettled or at least not supported by an ideal number of high-quality randomized controlled trials. Noridian, the MAC for a number of western states, recently posted a draft Local Coverage Determination (LCD) applicable in Oregon, Washington and Alaska that would in the future deny payment for CPT™ codes 64622, 64623, 64475 and 64476 (lumbar facet blocks and denervation procedures). These procedures have been under scrutiny since well before the HHS Officer of the Inspector General published its report on Medicare Payments for Facet Joint Injection Services in 2008, noting that 13 of 15 carriers had already adopted policies on facet joint injections as of 2006. Noridian, therefore, again reviewed the literature, met with its Carrier Advisory Committees, and was evidently motivated by the lack of consensus on facet therapies between the many societies representing pain physicians.

This non-coverage decision drew a strong response from the American Society of Anesthesiologists. In a letter dated August 31, 2009, ASA President Roger L. Moore, M.D. wrote “that the proposed non-coverage of facet therapies will inappropriately obstruct access by Medicare clients to treatment options that have proven valuable to patients and have been validated as appropriate care by both evidence in the scientific literature and expert opinion. The ASA does not believe that scientific evidence exists to support this abrupt decision to effectively terminate access to this care option by patients with debilitating, chronic low back pain.”

Acknowledging that there were some differences between guidelines published by several of the pain societies, the ASA letter announced a document that is likely to have a significant impact in the pain community. A new edition of the Guidelines of the Treatment of Chronic Pain is expected to be ratified by the American Society of Regional Anesthesia and Pain Medicine (ASRA) in September and by the ASA in October. Of practical importance to anesthesiologists and other pain physicians, the new Guidelines reflect a consensus opinion that (1) these facet procedures all require the use of either fluoroscopic or CT guidance for proper performance, and (2) diagnostic blocks must be performed before proceeding with therapeutic interventions. If the draft Noridian LCD becomes final in its present form, diagnostic injections and radiographic guidance will be essential to establish medical necessity in all the states that adopt the LCD. Radiographic guidance is already required for coverage by NGS, another MAC, as we noted in our August 3rd Alert. The implications for medical record documentation are clear.

Most LCDs applicable to anesthesiology relate to monitored anesthesia care or to pain procedures, the two areas in which medical necessity issues are most likely to arise. “Articles” containing interpretations, answers to common questions or billing guidance vary more in their subject matter. In Oklahoma, for instance, the MAC (Blue Cross and Blue Shield of Arkansas) last year updated its explanation of when an anesthesiologist or CRNA may bill for post-anesthesia care:

“Scenario: A patient undergoes surgery and anesthesia is provided by an anesthesiologist or a CRNA in the hospital. Ordinarily, anesthesia time stops when the patient has emerged and can be safely transferred to a post-anesthesia care unit. The anesthesiologist cannot transfer the patient to the post-anesthesia care unit because no bed is available. The anesthesiologist stays with the patient and provides post-anesthesia care in the OR suite. The anesthesiologist is providing care that would ordinarily be provided by post-anesthesia care staff. The additional time may be as much as 45 minutes.

“Background: Under 42 CFR 414.46, anesthesia time ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under post-operative care. It can be argued that, in the scenario presented, anesthesia time should stop when the patient is to be transferred to the post-anesthesia care unit. The fact that no bed is available would not affect this policy. In the OR suite, the anesthesiologist is performing care that post-anesthesia care staff would provide.

“Decision: While this would be a logical interpretation, CMS is proposing to allow a narrow exception to this interpretation. The anesthesiologist may be permitted to bill as much as one additional time unit (15 minutes) if the anesthesiologist is present with the patient in the OR suite, while the patient is awaiting transfer. We would apply the same policy to a medically directed CRNA; that is, the CRNA must be present with the patient in the OR suite, while the patient is awaiting transfer. In either case, the anesthesiologist or medically directed CRNA can only be present with one patient; the anesthesiologist or medically directed CRNA cannot bill for anesthesia time for more than one patient simultaneously.”

This policy of payment for actual time spent monitoring the patient because a PACU bed is not available also illustrates the point that MAC articles may contain unique, contradictory or even idiosyncratic solutions to problems that can occur anywhere.

Another MAC article, this one appearing on the CMS website for Palmetto GBA (South Carolina operations only), addresses medical necessity for ultrasound guidance for a joint injection without resorting to a full-blown LCD: 

“CPT codes 20600, 20610 and 76942

“In the clinic and outpatient setting, arthrocentesis and injections of small and deep-seated joints (i.e.: hips, sacroiliac, hands) may require ultrasonic guidance to ensure placement. However, the medical necessity for ultrasonic guidance for knee and shoulder joints would be extremely rare.

“Palmetto GBA may consider ultrasonic guidance for arthrocentesis and joint injections for shoulder and knee joints ONLY if the medical record documents needle placement difficulty due to conditions such as morbid obesity or severe joint deformity.

“Physicians who exceed their peers for ultrasound guidance in conjunction with arthrocentesis/joint injection may be targeted for review, Progressive Corrective Action, and Recovery Audit Contractor (RAC) referral.”

The big question for most practices is, “How do I make sure that I am up to date on all the national and local Medicare policies that apply to my practice?” No one can guarantee that every search will contain the same logic as the website’s search engine, or that a carrier website will be functioning perfectly. A combination of just two basic strategies should establish the good faith of your compliance efforts, though:

1. On the CMS website, the Medicare Coverage Database page contains a section with indices of LCDs and articles by state, by contractor and alphabetically. Check the applicable state for new policies regularly. You may also search on specific words.
    
2. Check your own MAC’s website at least monthly, and read and file paper bulletins you receive. Cigna’s September 2009 Part B Bulletin provides a good example of the important news you may find in this manner. In July CMS instructed the carriers to educate physicians and other providers on an update to the national Medicare policy (effective January 15, 2009) denying coverage for “a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient.” If your anesthesiologists are the slightest bit reluctant to insist on a proper “surgical pause” or “time out” in which all the members of the surgical team identify the patient, procedure and surgical site, they should know that “All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment..”

Familiarity with the applicable Medicare coverage and billing policies is a fundamental part of compliance. It is not always easy to find the answers, though, as numerous questions on the MGMA-Anesthesia Administration Assembly discussion board demonstrate. We hope that the above information will be useful to all our readers. If you have questions, please contact us at info@anesthesiallc.com.

Sincerely,

Tony Mira
President and CEO