2011 Anesthesia and Pain Changes
By: Bellinger Moody, RHIA, CPC, CCP, CPC-I, Executive Vice President of Compliance

12/23/2010

Below is a summary of changes that will impact anesthesia and pain management in calendar year 2011:

2011 DOCUMENTATION CODING BILLING COMPLIANCE & REIMBURSEMENT CHANGES

1.    Conversion Factor for Anesthesia Codes

Congress acted swiftly enough to avert a 23% physician fee schedule cut that would have decreased the national anesthesia conversion factor to $15.8085 from the current anesthesia conversion factor of $21.5696.  As a result, the current conversion factor ($21.5696) will remain in place until January 1, 2012.  Again, there will be no decrease in the anesthesia conversion factor for 2011.

2.    Conversion Factor for Ancillary Charges

The 2011 conversion factor for ancillary anesthesia charges (e.g. artline, CVP, Swan Ganz, post-op pain blocks, etc.) and chronic pain management procedures will also remain the same as the current 2010 conversion factor of $36.8729.  Therefore, there will be no decrease in Medicare reimbursements for your ancillary services provided in addition to the main anesthesia service.

3.    Increased Scrutiny of GA & GZ Modifiers

In 2011, the OIG will closely scrutinize claims with anesthesia procedures appended with the GA and GZ modifiers.   The GA and GZ modifiers are utilized when services are not considered medically necessary.   A couple of examples of its use in anesthesia are with anesthesia for gastrointestinal procedures (such as colonoscopies) and anesthesia for chronic pain procedures when the provider does not document or does not have a qualifying diagnosis for anesthesia or a physical status level of 3 or above.  Some provider group practices (Non-Medac  groups that I have audited over the course of the past 2 years)  have been incorrectly getting paid for services appended with these modifiers.   So, you can expect tighter reviews of this modifier.   In order to ensure that Medac properly applies these modifiers, you must:  (1) Provide a diagnosis that is payable according to your Medicare policy; or (2) Inform your Medac biller as to whether or not you have provided an ABN to the patient.

NOTE: IN ORDER TO OBTAIN A COPY OF THE POLICIES THAT CONTAIN THE PAYABLE DIAGNOSES FOR THE SERVICES IN WHICH THESE MODIFIERS FREQUENTLY APPLY, PLEASE CONTACT YOUR ACCOUNT MANAGER.

4.    PQRI is Now PQRS

The CMS incentive bonus system for reporting anesthesia quality measures has evolved once again.  What began as PVRP (Physician Voluntary Reporting Program) and morphed into PQRI (Physician Quality Reporting Initiative) is now PQRS (Physician Quality Reporting System).  There are no new anesthesia measures for 2011.  However, with the new name comes a new change for payment qualification.  The previous prerequisite of having to report on 80% of  eligible patients in order to qualify  for PQRS payments has been reduced to 50% in 2011 – which will make it easier to quality for the bonus. CMS 1503, pp. 1100 – 1103. However, on the other hand, what CMS giveth it also taketh away.  The bonus incentive for 2011 will be 1% instead of the previous 2%.  In calendar years 2012, 2013 and 2014 the bonus will decrease to 0.5%.  In 2015, if you do not report the measures, instead of bonus, you will be penalized 1.5% and in 2016 & after, if you do not report the measures the penalty will be 2%.  There same three (3) reportable measures for anesthesia that you reported on in 2010, will apply for 2011.

5.    ACA (Affordable Care Act) Maintenance of Certification (MOC) Program:  2012 - 2014

In calendar years 2012 through 2014, in accordance with Section 3002 of the Affordable Care Act, the new PQRS program will contain what is called a MOC (Maintenance of Certification) Program that will pay you an extra 0.5% of all allowable Medicare charges if you assess your practice according to certain measures and then make changes to strengthen your practice and then you perform a reassessment of your practice after making the changes.  The ASA (American Society of Anesthesiologists) is working with the AMA (American Medical Association) to creat its MOC program and get it approved.  The MOC program is for physicians only, not CRNA’s.  CMS 1503, pp. 1208 – 1220.

6.    EHR (Electronic Health Records) Incentive

The American Recovery & Reinvestment Act (Recovery Act) of 2009 created a $44,000 Medicare incentive payment for providers that implement an HER (Electronic Health Record).  If you are going to take advantage of this $44K per physician incentive payment you must start implementation this year or next year in order to receive all $44K over the next 5 years.  $18K will be paid in the first year (2011).  $12K will be paid in the second year (2012).  $8K will be paid in the third year (2013). $4K will be paid in the fourth year (2014) and $2K will be paid in the fifth and last year (2015).  If you are in a Health Professional Shortage Area (HPSA) you may receive an extra 10% per eligible professional .  Medicaid will also offer an incentive.  This incentive is $63,750 over 6 years.  However, you in order to receive the Medicaid incentive, 30% of your patient population must be Medicaid.  Additionally, you may participate in one or the other (Medicare OR Medicaid).   You cannot participate in both.  If you do not implement an EHR, penalties will begin in 2015 where you will lose a percentage(s) of the Medicare physician fee schedule.  Specifically, in 2015 your payments will be reduced by 1%.  In 2016 it will be reduced by 2%.  In 2017, it will be reduced by 3% and the Department of Health & Human Services (DHHS) is considering adopting a 5% reduction of your Medicare payments for  2018 and beyond. In order to qualify for the incentive payment, you must purchase a certified EHR.  You may see the list of certified EHRs at Onc_chpl.force.com/ehcert.   The earliest possible date for EHR payments is May 2011 – provided you have met the requirements, including registration and attestation, which begins in April 2011.  You must attest that you have used the EHR to capture 15 core measure and 5 non-core measures with the EHR system.  For example, 50% of patients have their vitals recorded electronically. The last day to register/attest for 2011 payments is 2/29/12.  Many anesthesiologists may not qualify for the EHR incentive payment because anyone whose total patient encounters are 90% inpatient is not an eligible physician.  However, some anesthesiologists will qualify.  The services performed in the ASC and outpatient hospital setting may exceed 10% and thus these anesthesiologists would be eligible for the incentive and may also be subject to the penalties that will occur after 2017.

7.    Problems Associated With Shorter Timely Filing Deadlines For Claims

On March 23, 2010, President Obama signed into Law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service claims.  In accordance with the new law (Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and the Code of Federal Regulations (CFR), 42, CFR Section 424.44; Section 6404 of the PPACA) – you now only have one year from the date of service to file a claim. The previous law allowed a provider to file a claims at the end of the year in the hear after the date of service, except if the date of service was in the last quarter, the provider had 2 years to file a claim, which made the timely filing limits extend up to 27 months in some cases.  

The new law also permits the Secretary of the Department of Health and Human Services to make certain exceptions to the one-year filing deadline, which raises some very relevant questions:  (1) What happens if RAC audit recaptures?  RACS can go back 3 years.   CMS says there is no exception to the timely filing rules for this.  DO NOT refile after a RAC audit – it is too late.  Use the RAC appeal process.  CMS-1503-FC, pp. 901-02; (2) What if private payer recoups?  For example, patient switched to Medicare at age 65, however commercial payer pays and then retracts. Can I refile under an exception? CMS says there is no exception to the timely filing rule for this.  CMS-1503-FC, p. 900; (3) What if you voluntarily repay Medicare and you need to refile after you repay?  CMS says you cannot extend the timely filing deadline.  You must use the appeal process.  CMS-1503-FC, p. 916; (4) What about refiling after a denial?  CMS says this is not an exception to the timely filing rule.  Specifically CMS states “ An  incomplete or rejected claim cannot act as a placeholder for a claim that has yet to be filed.” CMS-FC-1503, p. 917.

8.    ASA RVG Changes

There are some new changes in the ASA RVG that are worth mentioning.  On page vi of the RVG, CPT codes 64479 – 64484 include the following new language:  “with imaging guidance  (fluoroscopy or CT).  This new language is in line with the recent language change in the 2011 CPT – which means that these services (fluoroscopy or CT) are no longer separately reportable/payable in additional to the transforaminal epidural injection codes (CPT codes 64479-64484).  Additionally, “transforaminal epidural” has been removed for the Fluoroscopy CPT code 77003, indicating that it is not separately reportable. 

On page vii of the 2011 ASA RVG, there was a new comment added to code 00670 – RVG Comment:  “Code 00670 is appropriate if the surgical procedure is performed with spinal instrumentation, on multiple vertebral levels, or with an add-on code indicating multi-level procedures”.  This new language confirms that the coder may use this code for multiple vertebral levels or with an add-on code indicating multi-level procedures.  Therefore, please ensure that you document all of the levels that the surgeon is performing arthrodesis on and be sure to document whether instrumentation was utilized.

On page 57 of the 2011 ASA RVG, there is a new clarification that states “Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time.” Therefore, if the block is done prior to induction or after emergence the time must be deducted and in such cases it may be necessary to report discontinuous time.

On page 60 of the 2011 ASA RVG the ASA provides an example which clarifies that “when general anesthesia is administered and epidural or nerve block injections are performed to provide post-operative analgesia, they are separate and distinct services and are reported in addition to the anesthesia service” and it does not matter whether the block or catheter was performed preoperatively, intraoperatively or postoperatively.

On page 60 of the 2011 ASA RVG, the ASA provides an example of a “total knee replacement surgery where a patient receives a regional anesthetic  and a postoperative pain management agent through the same epidural catheter.  When the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone (01402)."

One page 61 of the 2011 ASA RVG, the ASA gives an example of when it is appropriate to report a pain procedure along with an anesthesia service:  “A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery.  The anesthesiologist reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedure of knee joint).  The epidural catheter is left in place for postoperative pain management. The anesthesiologist should NOT also report codes 62311 (injection of diagnostic or therapeutic substance) or 01996 (daily management of epidural) on the date of surgery.  CPT code 01996 may be reported with one unit of service per day on the subsequent days until the catheter is removed. On the other hand, if the anesthesiologist performed general anesthesia reported as CPT code 01382 and reasonably believes that postoperative pain is likely to be sufficient to warrant and epidural catheter, CPT code 62319-59 may be reported indicating that this is a separate service from the anesthesia service. In this instance, the service is separately payable whether the catheter is placed before, during, or after the surgery.  If the epidural catheter was placed on a different date than the surgery, modifier 59 would not be necessary.”

9.    CRNA Pass Through Payments

Most hospitals are paid on a DRG (Diagnosis Related Group) basis and cannot write off CRNA costs.  Beginning in 2011, there will be a CRNA pass-through payment for Rural Hospitals and Critical Access Hospitals.  Effect:   (1) CRNA salaries paid by Medicare; (2) Shift employment to the hospital.  42 CFR Parts 410, 411, 412, 413, 416, 419, and 489;  CMS-1504-FC and CMS-1498-IFC2.

10.    New Patient Visits – 3 Year Rule Implications

Beginning in 2011, in order for a chronic pain doc to bill a new patient visit when an anesthesiologist in the same group has provided anesthesia to the same patient in the past 3 years, the chronic pain doc must have filed an 855R form with Medicare, designating himself as specialty 09 (interventional pain) or 72 (chronic pain).   If you do not file this specialty designation form , CMS will retract payment for the new patient visit if you are audited because they will not consider the two physicians as having a separate specialty unless they are registered as such.

11.    Regular Inpatient  E&M vs Prolonged Visit E&M

In accordance with the new 2011 Final Rule -- CMS-1503-FC, p. 52, prolonged visit E&M codes have more stringent time limitations than regular inpatient visit E&Ms.  Normal Inpatient E&M Codes allow unit/floor time plus face-to-face time.  However, in accordance with the new 2001 Final Rule, Medicare limits inpatient prolonged visit codes (CPT codes 99354 – 99356) to face-to-face time only.


12.     CPT Changes For Transforaminal Codes

Fluoroscopy and CT are now bundled into the Transforaminal Injection codes  (64479 – 64484).  However, please keep in mind that imaging guidance is still required – you just cannot bill for it. The Transforaminal Epidural Codes have otherwise remained the same unless ultrasound guidance is used.  If ultrasound guidance is used, you must now use the new  “New Technology Codes” 0228T, 0229T, 0230T, 0231T. This applies to all payers, not just Medicare.  The correct coding for an injection at T12 – L1, is 64479, 64480.


13.    New Facet Ultrasound Codes

The Facet Injection codes (64490 – 64495) have remained the same unless ultrasound guidance is utilized.  If ultrasound guidance is utilized, you must use new “New Technology Codes” 0213T, 0214T, 0215T, 0216T, 0217T, 0218T. Please keep in mind that imaging guidance (Fluoro and CT) have been bundled with these codes since January 1, 2010.  The correct coding for an injection at T12 –L1, is 64490, 64492.

14.    ASA Crosswalk Changes Affecting Pain Management

The 2011 ASA crosswalk removed anesthesia codes 01991, 01992 as crossovers for 62310, 62311, 62318, 62319, 62273 and now states that “Anesthesia Care Not Typically Required” for these procedures.  So, what does this mean?  It means you can anticipate denials on claims with anesthesia for these chronic pain injections.

The 2011 ASA crosswalk removed anesthesia codes 01935, 01936 as crossovers for all of the facet codes (64490 – 64495) and states “Anesthesia Care Not Typically Required” for these procedures.  Again, this means you may anticipate denials on claims with anesthesia for these chronic pain injections.

15.    New Smoking Cessation Codes

MedLearn Matters Number :  MM7133 establishes new G codes for smoking cessation counseling for patients who smoke.   However, the new codes are limited to patients who are not symptomatic and not addicted. The goal is to counsel these patients so that they do not become addicted or symptomatic. The services are limited to 2 visits per year, and the co-pays and deductibles are waived. The codes are G0436, (4 to 1m minutes), and G0437, greater than 10 minutes. Diagnosis codes V15.82 (History of tobacco use) and 305.1 (Non-dependent tobacco use disorder) are the diagnosis codes that you should utilize for these services.  Counseling must be performed by a “qualified physician or Medicare-recognized practitioner”.

16.    New CMS Urine Drug Screen Codes

CMS created a new HCPCS level II Code and revised an existing code for urine drug screening.   The new code is G0434.  The revised existing code is G0431. As  previously published on December 20, 2010 in the Medac  Client Alert by Justin Vaughn, MDiv., CPC (Director of Compliance, Medac , Inc.) in which Mr. Vaughn states:  “CMS revised the descriptor for G0431 to now read, “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.”  Because this is a “per patient encounter” code, you may only bill one unit for this screening procedure regardless of the number of dipsticks employed during the session.  However, CMS has set the reimbursement for this code at five times the rate for the deleted code, G0430.”

Mr. Vaughn further explains that “CMS created  the new code, G0434, “Drug screen, other than chromatographic; any number of drug classes by CLIA waived test or moderate complexity test, per patient encounter.”  This code is essentially meant to replace deleted code G0430, and will be paid at a similar rate.  Again, due to the “per patient encounter” part of the descriptor, you may not bill multiple units when submitting G0434 on the claim form.”

In conclusion, Mr. Vaughn states:  “The AMA has created a new code, 80104, “Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure.” Medicare will not recognize 80100 or 80104.  Instead, providers would use G0431 or G0434. We anticipate that further clarification in the use of these codes will be released by the AMA, CPT and/or CMS in the weeks ahead."

17.    New Peripheral Nerve Stimulator Codes

CPT 2011 lists new CPT codes for peripheral nerve stimulation.   For Posterior Tibial neurostimulation, see CPT code 64566.  For cranial nerve electrode and generator implantation, revision, and removal se CPT codes (64568-64570).


18.     New Salivary Gland Chemodenervation Code

CPT 2011 lists a new CPT code for destruction by neurolytic agent.  CPT code 64611 is for chemodenervation of the parotid and submandibular salivary glands and it is defined and including bilateral.

19.    New CPT Code Comment:  Neuroplasty vs Neurolysis

If you are documenting neuroplasty in your procedure description for lysis of adhesions, you must remove it, because the CPT Code now defines “neuroplasty” as “surgical decompression” and instructs users that lysis of adhesions should be described as “percutaneous neurolysis.”

20.    New E&M  Subsequent Observation Codes

In 2011, there are new Subsequent Observation Care codes in the E&M section of the CPT. The guidelines for CPT codes 99224, 99225, and 99226 state that “all levels of subsequent observation care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status (i.e., changes in history, physical condition, and response to management) since the last assessment by the physician”.

21.    CCI Bundles Fluoro With Cervical & Lumbar Sympathtic Nerve Blocks, Celiac Plexus Block, Peripheral Nerve Electrode Code and Intercostal Nerve Destruction Code

Version 16.1 of the CCI (Correct Coding Initiative) has bundles fluoroscopy into CPT codes 64510, 64520, 64530, 64555, and 64620.  Fluoroscopy is no longer separately billable to Medicare with these procedures.

22.    New Quality/Cost Measure To Be Adopted:  ACA Value Based Modifier

As a requirement of the ACA (Affordable Care Act) --  in 2012 there will be a new quality of care/cost reduction modifier which will pay providers extra money beginning in 2015. There will be new measures to report called “GEM” measures whereby the provider is assessed against his peers in his geographic locality and against his peers in his discipline nationally.  “GEM” stands for “Generating Medicare Physician Quality Performance Measurement Results”.   Providers will be compared to others in the same geographic as well as compared to others nationally and will be rated and sorted by 10th, 50th, and 90th percentiles. Depending on how much money you cost the government, on average, per patient encounter, will determine whether you get the extra payment.  CMS-1503-FC, p. 653

NEW OR AMENDED REGULATIONS:  AFFORDABLE CARE ACT PROVISIONS (ACA)

23.    Anti-Kickback Statute Amendment

The anti-kickback statute has been amended to delete the requirement that specific intent to violate the statute is required or that the provider has knowledge of the anti-kickback statute.  Simply stated, Kickbacks are going to be easier to prove and specific intent to violate statute is no longer necessary for the government to prove a violation.   Additionally,  knowledge of the kickback statute is not needed.

24.    ACA Establishes Penalty for Delay of CMS Audit or Investigation

There will be a $15,000/day penalty for delaying a CMS related audit or investigation. So, if you get an audit letter demanding documents within 14 days, you need to implement some type of procedure of getting that letter immediately in the hands of the right person, so there will be no delay in getting the requested audit documents to the CMS contractor.  I recommend that you designate the proper handling of a request to your compliance officer for your practice and have him/her establish a protocol.

25.    ACA Establishes Suspension of Payment Provision

CMS can suspend all your payments if it receives “credible allegations of fraud” and according to the proposed regulations, those credible allegations are defined to include, among other things, online complaints, which the OIG allows one to make anonymously.    Simply put, they don’t need proof, all they require is an allegation.

26.    ACA Establishes 60 Day Requirement For Credit Balance Resolution

Under the provisions of the ACA, Effective March 23, 2010, you now have only 60 days to repay an identified credit balance owed to a government payer.  Failure to return an overpayment to a government payer within 60 days is an automatic violation of the FCA (False Claims Act) which means that there can be a $10,000 fine per unpaid claim violation. This  requirement applies to “any person” that knows of the overpayment and “does not report and return”.  You must advise of the reason for the overpayment.

27.    ACA Establishes Manufacturer Disclosure Requirements

Beginning in 2012, any drug or device manufacturer that gives you anything of value in excess of $10 must report it to the government. That information will be made available to the public on a website. This does not apply to product samples, educational materials for patients, discounts including rebates, or short term loans for a covered device. They are required to report any transfers of value by March 31, 2013 including name of physician and amount.

28.     ACA Establishes Requirement For Adoption Of Provider Compliance Programs

Prior to the ACA, Compliance Programs (Plans) for providers have only been “recommended”.  Well under ACA providers are now required to adopt a compliance program (plan).  The regulations as to which providers are required to have them should be published in 2011.

29.    ACA Mandates RACs (Recovery Audit Contractors) for Medicaid

ACA requires Medicaid in all states to have state RAC contracts by 12/31/2010.  This means that now also have external auditors for Medicaid as well as internal auditors for Medicaid – just as Medicare does and they (RAC auditors) are paid on a contingency fee basis.

30.    FCA (False Claims Act) Changes

There is a new $50,000 penalty for any false statement made in a provider application (855 form), so please make sure your providers understand that when they sign the 855 form, it must be 100% accurate.

The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.