Gastrointestinal endoscopy is one of the safest and most commonly performed adult procedures. The record of safety extends to the sedation or anesthesia for both upper and lower GI endoscopy.  Because of both the safety and the frequency of the procedure, anesthesia for GI endoscopy has been under scrutiny by health plans for a decade or more.  Lately, the number of claims denied for lack of “medical necessity” for endoscopic anesthesia services have once again been growing.  Without taking any position on the merits of anesthesia vs. moderate sedation in connection with endoscopies and especially colonoscopies, we would like to remind our audience of the principles followed by payers in evaluating the medical necessity of anesthesia for these procedures. The differences between anesthesia and moderate sedation Moderate sedation (aka “conscious sedation”) is a “drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile...

As happens every year, Congress stepped in at the last minute and blocked the Sustainable Growth Rate (SGR) cuts in Medicare payments to physicians.  On the afternoon of January 1, 2013, the House of Representatives adopted legislation passed earlier that day by the Senate, the "American Taxpayer Relief Act of 2012.” The bill prevented a plunge over the “fiscal cliff” by postponing across-the-board spending reductions and also overrode the 26.5 percent Medicare fee schedule cut that technically had already gone into effect on the morning of passage.   Congress’ action replaced the SGR reduction with a zero percent update for services provided from January 1, 2013, through December 31, 2013. Because of adjustments in the practice expense component of the anesthesia conversion factor (CF), the 2013 national average CF is $0.50 higher than last year’s CF, i.e., $21.9243.  This is 38 percent higher than the $15.93 CF announced in November 2012.   Actual...

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,...

  MEDICARE PAYMENTS AFTER DECEMBER 31st If we go into the New Year without legislation to stop the economy from going over the fiscal cliff—as appears almost certain—there will be no just-in-time SGR fix either.  The Medicare conversion factor applicable to services provided from January 1st onwards will be 26.5% lower, unless and until Congress corrects the problem.  Since the earliest that Medicare will pay claims will be January 14th, however, there is time for Congress to take the necessary action and prevent any remittances from going out at the lower rate, subject to later adjustment.   It is instructive to look at a six-year history of the dates on which Congress passed legislation each year avoiding the impact of the SGR (American Medical News, December 24, 2012): 2006-4.4%0.2%Feb. 8, 2006* 2007-5%0%Dec. 20, 2006 2008 (Jan.–June)-10.1%0.5%Dec. 29, 2007 2008 (July–Dec.)-10.6%0%July 15, 2008* 2009N/A1.1%N/A 2010 (Jan.–Feb.)-21.3%0%Dec. 19, 2009 2010 March-21.3%0%March 2, 2010* 2010...

  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...

Everyone involved in the healthcare industry will inevitably learn about the confusing aspects of medical health insurance. Just when you thought you had a grasp on the insurance marketplace another complexity presents itself.  Sometimes what you might have thought of as an insurance plan turns out not to be insurance at all. There is a variety of well-known insurance plans available in the market today. Some of these plans are government-run, starting with Medicare and Medicaid. Others are private or commercial managed care plans offered by entities that include Blue Cross and Blue Shield, United Healthcare or Aetna.  Then there is a less well known group of companies that market themselves as health benefit plans but that are in reality simply claims repricers, or discount brokers and vendors, i.e., “rental networks” or ”silent PPOs.” What is a “Rental Network PPO?” A rental network preferred provider organization or medical discount network or...

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...

With a new calendar year just over two months away, the medical and healthcare communities have begun the annual flurry of end-game activity seeking to influence payment rates.  Anesthesiologists need little reminder of the Sustainable Growth Rate (SGR) threat and the 27 percent cut in Medicare payment that will take effect on January 1, 2013, unless Congress intervenes. On October 15th, more than 100 national medical societies, including the American Society of Anesthesiologists, sent letters to the Senate Finance Committee, the House Ways and Means Committee and the House Energy and Commerce Committee highlighting the urgency of fixing the SGR problem for a new reason: The sustainable growth rate (SGR) formula is an enormous impediment to successful health care delivery and payment reforms that can improve the quality of patient care while lowering growth in costs. Physicians facing the constant specter of severe cuts under the SGR cannot invest their time,...

F1RSTUseTM is the first—and only—full-service EHR management platform built exclusively for anesthesiologists and pain management specialists to satisfy with ease Stage 1 of Meaningful Use as required to earn the Medicare EHR incentive payment.  It is the only product that provides the full service measures to ensure success:  tracking the necessary data points, providing reports of successful measures and ensuring that you are meeting all of the CMS requirements.As a number of physicians have begun to incorporate the F1RSTUse system into their workflow, additional questions regarding the Meaningful Use program have been received.  Read on to learn more about F1RSTUse and how it can support your Meaningful Use program.This checklist has been compiled from questions raised by anesthesiologists, colleagues, facilities, and patients.  1. What is the maximum incentive payment if I start now? – $39,000.  If you have not already enrolled in the F1RSTUse system, the original $44,000 incentive payment is...