February 22, 2010

Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Program Safeguard Contractors and other agencies including the Department of Justice are becoming more aggressive in their auditing activities. To help you stay out of their viewfinders, we offer an updated list of some top compliance risks.

1. Anesthesia time. The venerable ASA and Medicare definition states that “Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.” Here are some compliance issues that sometimes arise:
1. Billing time for blocks or invasive monitoring lines placed prior to induction is a potential area of scrutiny. Although there has been a lot of debate on this issue in the industry and CMS has not formally addressed it, the ASA House of Delegates approved a statement entitled “Reporting Postoperative Pain Procedures in Conjunction with Anesthesia” in 2007 (and amended it in 2008). The ASA statement references several authorities including CPT Assistant articles and notes that time spent on pre- or postoperative placement of the block should not be included in reported anesthetic time. The rationale is that lines and blocks placed prior to induction of anesthesia (whether in the pre-operative holding area or the operating room) are non time-based services and should not be included in total anesthesia minutes billed. These lines and blocks are instead billed as separate “flat fee” surgical codes on the insurance claim form.
2. The time spent placing blocks or inserting lines after induction does not need to be deducted from total anesthesia time. Again, the ASA statement cites several references from the CPT Assistant noting that time after induction need not be deducted.
3. Rounding start and stop times to the nearest 5 minute interval is contrary to Medicare instructions, which require the reporting of actual time, to the minute. Coordinating clocks in the OR is an ongoing problem for many departments. It is important to find a way to avoid time inconsistencies in documenting each anesthesia case. If it is necessary to correct start and stop times for purposes of billing, especially when it comes to medically directed cases, the anesthesia record should be amended accordingly.
2. What is included in the anesthesia service? The Anesthesia Guidelines published in the ASA Relative Value Guide (RVG) provide that “A Base Value is listed for anesthetic management of most surgical procedures. This includes the value of all usual anesthesia services except the time actually spent in anesthesia care and any modifiers. The usual anesthesia services included in the Base Value include the usual pre-operative and post-operative visits, the administration of fluids and/or blood products incident to the anesthesia care and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). Placement of arterial, central venous and pulmonary artery catheters and use of transesophageal echocardiography (TEE) are not included in the base unit value.” According to the anesthesia chapter of the CCI manual, there are a number of services considered integral to anesthesia. In appropriate circumstances, though, modifiers can be reported if the services are unrelated to the anesthesia service.

1. Pre- and post-anesthesia visits are generally included in the base units for the anesthesia service and are considered part of the anesthesia package for CCI edit purposes. According to the ASA statement, “[t]he usual anesthesia services included in the Base Value include the usual pre-operative and post-operative visits.” If all of the elements of an evaluation and management service – history, examination, level of medical decision-making – are performed and documented and the service is more extensive than the typical pre-op visit, it may be appropriate to report the visit. This would be the case if, for example, the anesthesiologist were performing a full H&P to clear the patient for surgery, or if the post-op visit is for pain management (but not IV PCA management ) rather than to follow up on recovery from the anesthetic.

   Billing separately for visits during the perioperative period creates a greater risk of scrutiny than in the past. Recently the RAC for Region D listed pre- and post-op visits as an anesthesia focus area on its website. Such a posting only occurs after CMS has approved the issue. It seems quite possible, therefore, that other auditing agencies will be looking for claims for visits unbundled from the anesthesia service. Some anesthesia practices have already begun to receive requests for records on these issues.

2. Duramorph injections (CPT™ code 62311) placed in conjunction with combined spinal epidurals for c-section patients like all injections administered through an existing catheter)  may not be billed separately.
3. IV PCA management (codes 99231-99233) should not be billed to Medicare. Private payers, on the other hand, may recognize and pay for the service.
4. TEE for monitoring purposes, i.e. where the physician does not prepare a written report, should be billed using code 93318 and not 93312 or 93313, which are diagnostic TEE services.
3. Documentation is and ever shall be key. More and more anesthesiologists use electronic anesthesia records with decision trees, auto-reminders and error-checking routines, but it still behooves everyone to know the rules and to make sure that everything required to be documented is in fact in the record.
1. The medical direction regulations specifically provide that the anesthesiologist “alone inclusively documents in the patient’s medical record that the [medical direction requirements] have been satisfied….” Anesthesiologists should pay close attention to those requirements, and to the extent that they are using global attestations, they should use them carefully. If an anesthesiologist begins a case and then hands it off to another member of the group, both physicians will need to attest to medical direction conditions that they performed, for example. In some cases, the use of a global attestation will not work.
2. Emergencies to which an anesthesiologist attends while medically directing must be of short duration and in the immediate area. If the anesthesiologist becomes involved in another procedure and is not immediately available to return to his or her medically directed cases, those cases must be billed as “medically supervised” (modifier- AD) or as “CRNA service without physician supervision”  (modifier- QZ) as appropriate.
3. The emergency modifier (add-on code 99140) should be reserved for true emergencies, which can be identified, according to one anesthesiologist of our acquaintance, as situations where the surgeon comes running to the OR. An emergency only exists “when delay in treatment would lead to a significant increase in the threat to life or body part,” as stated in the ASA RVG. Early morning labor and delivery, or cases added to the schedule after hours, do not automatically constitute 99140 emergencies.
4. Consultations require documentation of a request by the referring physician. Medicare no longer recognizes the consultation codes (99241-99255) but most private payers have not followed suit to date.
5. Ultrasound guidance (codes 76937-26 and 76942-26) requires a permanent recorded image in the patient’s medical record.
4. Arterial lines and CVPs placed by CRNAs are not anesthesia services. Only anesthesia services can be medically directed and therefore the anesthesiologist cannot bill for overseeing these procedures when performed by a nurse. Placing the lines can be billed in the nurse’s name, but only if they are within his or her scope of practice under state law – and if the group employs or leases the nurses, not if their services are being billed by the hospital.
5. Waiving patient co-payments or deductibles has long been a compliance risk. From the insurance company perspective, this practice lowers the actual charge. If the full charge is $200 and the patient has a 20% co-payment, the anesthesiologist must bill the patient for the $40. Otherwise the actual charge is $160, and to report $200 on the claim is false. Waiving a Medicare patient’s responsibility could also be seen as a violation of the very broad federal anti-kickback statute if the patient is in a position to refer Medicare patients to the practice and if the financial hardship/special consideration exception does not apply.

The fourteen compliance risks described above are those that we see more frequently than any others. Fortunately most of us do not know of any anesthesia practices that have found themselves in major Fraud and Abuse trouble without, at a minimum, gross negligence in their billing. We are aware, however, of increased enforcement interest and activity. We hope that our list will be helpful to you in your own compliance efforts.

Sincerely,

Tony Mira
President and CEO

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