The 2013 CPT® Changes and Codebook are now available to health care providers.  Overall, the 2013 changes include 186 new codes, 119 deleted codes, and 263 revised codes. In addition CPT revised 18 modifiers and updated 150 guidelines.  The very good news for anesthesia and pain management providers is only a small handful of these changes directly impact the services they routinely provide.  Following are general comments regarding the 2013 changes: No Anesthesia codes were deleted, revised, or added for 2013.Pain management providers should take note of the four revised codes and one new code in the nervous system section of CPT 2013. The majority of changes occur in the denervation subsection, where CPT revised codes 64612 and 64614 and added 64615 for bilateral chemodenervation of muscles innervated by the facial, trigeminal, cervical spinal and accessory nerves.CPT also changed the parenthetical note for code 76942, ultrasound guidance for needle placement (eg,...

  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...

It is a question asked quite often: Is marking a check box on the anesthesia record sufficient documentation?  For medical review and for billing purposes?Check boxes are a very convenient way to document services provided to a patient with minimal time spent dictating or writing out everything that is done.  We see check boxes on pre-operative assessments, anesthesia records and evaluation and management service (E&M) forms, just to name a few.  Templates increase the efficiency of the clinical documentation, but are they an acceptable form of documentation?On November 9, 2012, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 438, which provides some insight into CMS’ views on the use of templates in medical record documentation and the risks, as well as some guidance.In its Transmittal, CMS stated its position on the use of templates and check boxes:CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does...

Across the United States and the District of Columbia, the average anesthesia managed care contract rate during the first several months of 2012 was $67.94.That figure comes from the latest ASA survey of commercial fees paid for anesthesia services, published in the November issue of the ASA NEWSLETTER.  ASA fields the survey electronically every year, soliciting responses through email, committee list servs, newsletters and the website.  Whether the responses are representative of the specialty is an open question, but the overall consistency of the survey results from year to year, since it was initiated in the mid-1990s, supplies a certain measure of credibility.  The survey leverages the relatively small number of respondents by asking for the conversion factors (“CFs” or “unit rates”) for five of each group’s largest managed care contract rates.The first thing to note is that $67.94 is a weighted average of averages across up to five contracts for each of...

Memorial Hospital—a hypothetical “Memorial Hospital”—considers itself extremely fortunate to have renewed its contract with Associated Anesthesiologists—a hypothetical “Associated Anesthesiologists”—for another three years.   Although one newly-formed anesthesia management company (AMC) and one freshly-capitalized market leader among AMCs have approached Memorial, the hospital let the anesthesia group know that it would not be entertaining any proposal.  If Memorial were to enumerate the attributes of Associated Anesthesiologists for which it is so grateful, the list would be as follows:1. Associated Anesthesiologists keeps the surgeons happy.Surgical volume is up slightly and the trend line is positive.  The last surgeon to approach hospital administration with a complaint about OR time and the service provided by the anesthesiologists herself left the area several years ago.  The rumor about the orthopedic surgeons building their own ambulatory surgery center pops up every year, but the chief of the service is not interested.2. Associated Anesthesiologists no longer receives income supplementation.The...

Now that the elections are over, nationwide attention has turned to the so-called “fiscal cliff.”  The fiscal cliff refers to the effective date of automatic cuts in spending combined with increases in taxes mandated by law.   It has been called a year-end “perfect storm” and “taxmageddon.”  One commentator at CNN referred to the fiscal cliff as “the legislative equivalent of a slow-motion train wreck.” Putting politics aside, unless new legislation is enacted between now and the end of the year, the fiscal cliff will have an impact on you and your anesthesia practice.  In this week’s Alert, we summarize some of the changes slated to take effect at the start of 2013.  This is only a summary and not tax advice.  You should consult your tax advisor regarding your response to this possible fiscal cliff.Income TaxesThe table below is based on gross income after exemptions:SingleMarried Filing JointlyCurrent Tax Bracket2013 Tax Bracket$0–$8,700$0–$17,40010%15%$8,700–$35,350$17,400–$70,70015%18%$35,350–$85,650$70,700–$142,70025%28%$85,650–$178,650$142,700–$217,45028%31%$178,650–$388,350$217,450–$388,35033%36%$388,350 +$388,350...

As you expected, if you have been reading our Alerts, the final version of the Medicare Physician Fee Schedule Rule for 2013 contains a massive payment reduction: Medicare Conversion Factors  20122013Difference Anesthesia Services(national average)$21.52$15.93-26.0% Other Services$34.0376$25.0008-26.5%   As you also know, the 26% and 26.5% cuts are unlikely to go into effect.  If they do go into effect, because Congress fails to take action before December 31st, Congress will almost certainly enact a fix early in the new year, as it has done every year but one (2002) since the Sustainable Growth Rate (SGR) formula first start mandating reduction. In announcing the Final Rule, the Centers for Medicare and Medicaid Services (CMS) itself said: The final rule with comment period also includes a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates for more than 1 million physicians and non-physician practitioners under the Balanced Budget Act of 1997’s Sustainable Growth...

[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...

There continues to be considerable confusion as to which post operative pain management services are reimbursable and the criteria for ensuring that payment for them can be consistently obtained. Part of the issue has to do with the different modes of acute pain management currently being used across the country, but another point of confusion pertains to the provider categories for each type of service. While individual payor policies may vary, the essential parameters are quite consistent across all jurisdictions.  Irrespective of what a particular group’s billing practices have been historically, it is a good time to reexamine previous assumptions and review current guidelines. The fact that a given payor has not questioned charges for a particular service historically is no guarantee that payments were received legitimately or that a subsequent audit might not uncover a significant overpayment. It should be noted that contract terms can be misleading; and all terms...

Effective November 1, 2012, Wisconsin Act 160 (Act 160) establishes a licensure requirement for anesthesiologist assistants (AAs).  Prior to Act 160, AAs practiced under delegated authority.  Act 160 also established the requirements for obtaining AA licensure, AA’s scope of practice, anesthesiologist supervision requirements as well as a Council on Anesthesiologist Assistants.  This announcement summarizes some of the key aspects of the new law that Wisconsin anesthesiology providers need to know. AA Scope of Practice Act 160 provides that an AA may assist an anesthesiologist in the delivery of medical care.  The medical care tasks that may be assigned by the supervising anesthesiologist, falling within the AA’s scope of practice, are the following: Developing and implementing an anesthesia care plan for the patient;Obtaining a comprehensive patient history and performing relevant elements of a physical exam;Pretesting and calibrating anesthesia delivery systems and obtaining and interpreting information from the systems and from monitors;Implementing medically accepted...

    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...

Anesthesia services have spread far beyond the operating room over the past several decades. The demand for sedation and analgesia has gone up dramatically, reflecting not just population growth but also an increasing variety of nonsurgical procedures requiring that patients be protected against pain or prevented from moving.Meanwhile, the numbers of anesthesiologists, nurse anesthetists and anesthesiologist assistants have not kept pace.  Leaving the OR for other floors or even buildings, where the anesthesia professional may have a single patient to care for, reduces his or her efficiency and costs the practice too much uncompensated time.  Into the breach have stepped clinicians from other specialties and disciplines.  This Alert will focus on the role of registered nurses in procedural sedation, also known as “conscious” or “moderate” sedation.The Continuum of Anesthesia:  Moderate and Deep SedationGranted that anesthesia is a continuum, agreeing on the definitions is nevertheless important.  Disagreement on terminology, or at least on...

  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...

  With the ever-rising cost of healthcare, all parties are looking for ways to finance it. From high deductible health plans with savings components to consumer credit tools such as credit cards and loans, the face of healthcare financing is changing. The challenge for anesthesia in this ever-changing world comes back to the physician-patient relationship. As noted in previous articles “The Benefits of Strategy” from the Winter 2012 issue of The Communique and “Planning for Payor Negotiations” from the Spring 2012 issue of The Communique, high deductible health plans (HDHPs) are a growing health insurance product line. This puts a greater emphasis on collecting larger sums of money from the patient. Moreover, the current economic climate has put a strain on the safety nets that are in place to help those with fewer resources. The self-pay category is growing and the need to address this issue is at the forefront in...

  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...

We are in the middle of the ASA Annual Meeting, which draws thousands of anesthesiologists from across the country to spend several days at meetings and lectures, all without compensation.  We know the incentive for the rank-and-file:  the opportunity to attend an incomparable array of refresher courses, panel discussions and other continuing education offerings.  Hundreds of anesthesiologists come to educate others and participate in committee and board activities as specialty leaders. The sight of so many physicians spending valuable time together away from the operating room, along with some questions heard lately, made us wonder how anesthesia groups secure attendance at their own internal meetings.  Board and other governance meetings, finance and employment committee meetings, and all-employee and departmental meetings are important—indeed, they are indispensable to effective group management.  While recognizing the need to conduct business by meeting, few individuals wish they could attend even more meetings, and many people will...

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...

By Abby Pendleton, Esq., Carey Kalmowitz, Esq. and Adrienne Dresevic, Esq. The Health Law Partners, P.C., Southfield, MI On June 1, 2012, the Department of Health and Human Services Office of Inspector General (the “OIG”) issued its Advisory Opinion No. 12-06, which provides long-awaited guidance to the health care industry regarding the legal permissibility of an anesthesia delivery service model commonly referred to as the “company model.” Insofar as Advisory Opinion No. 12-06 is the initial OIG guidance that specifically focuses on such an arrangement and determines that the factual paradigms presented implicate risks under the Medicare and Medicaid Antikickback Statute (the “AKS”), this Advisory Opinion understandably is capturing broad attention within the medical and legal communities. While OIG Advisory Opinion 12-06 clarifies the almost-axiomatic observation that company model arrangements, especially those that contain the indicia that the OIG historically has identified as problematic under the AKS, certainly have the potential...

The Office of the Inspector General (OIG) within the Department of Health and Human Services has published its Work Plan for 2013.  On the list of Medicare issues on which the OIG will focus next year is the following: Anesthesia Services—Payments for Personally Performed Services (New) We will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. We will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” service code modifier met Medicare requirements. Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed or medically directed. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch.12, § 50) The service code “AA” modifier is used for anesthesia services personally performed by an anesthesiologist, and the “QK” modifier is used for medical direction of two, three, or four concurrent...

While the eventual fate of the Patient Protection Affordable Care Act (PPACA) will be decided in the near future, by either the Supreme Court or the next Congress and Administration, what is not open for debate is that healthcare has changed. As the business of medicine evolves to accommodate the changes called for in the healthcare reform laws, so should anesthesiologists anticipate their place in the new environment. The physician group that is able to make informed decisions will be best positioned to evolve and thrive in this era of change. Just like the old Saturday morning cartoon said, “Knowledge Is Power”; by gathering, understanding and responding to information, anesthesiologists can be certain to meet the needs of their clients and proactively position themselves as a catalyst for change.One way of taking that proactive step is to use data to help shine a light on the inner workings of your anesthesia...