2013 Anesthesia and Pain Updates

-->April 18, 2013Billing & Compliance Alerts

    2013 Anesthesia and Pain Updates

    By Christine Locay, JD, RHIA, CPC
    Senior Vice President of Compliance


    Anesthesia Coding Updates

    CPT Changes: Anesthesia Codes

    In Current Procedural Terminology (CPT) 2013, there were no new or deleted anesthesia codes.

    There was one revision to 01991 (anesthesia for blocks, other than prone position) and 01992 (anesthesia for blocks, prone position).  These codes used to state “when block or injection is performed by a different provider.”  The descriptors now state “when block or injection is performed by a different physician or other qualified health care professional.”
    CPT included the term “other qualified health care professional” to emphasize that CPT does not limit code reporting to specific specialties or providers; instead, scope of practice laws, regulations, contracts, and hospital policy/bylaws determine whether a provider is qualified to perform a service.  According to CPT a “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports the professional service.”   CPT excludes clinical staff who do not report their services independently from the definition of “other qualified health care professional.”

    CPT Changes: Ancillary Anesthesia Services

    The venipuncture codes (36400-36410) and evaluation and management services (E&M’s or visits) were revised to include the “other qualified health care professional” descriptor discussed above.

    Relative Value Guide (RVG) Changes: Anesthesia

    The ASA publishes the RVG annually.  The RVG includes recommended base unit values for anesthesia and pain services.  It also includes various ASA position statements that impact billing for anesthesia.

    • In the 2013 RVG, the ASA included the following comment for code 00524 (anesthesia for pneumocentesis): “Pneumocentesis is an old non-specific term to describe what is currently thoracocentesis.”
    • The RVG includes an update in the Obstetric Anesthesia section.  The RVG lists examples of “reasonable” labor time billing methodologies.  The following method had been interpreted by providers in different ways: “Base units plus time reported in minutes (insertion through delivery).”  Some providers reported delivery of the infant as anesthesia stop and others argued that delivery includes other events, such as delivery of the placenta.  In the 2013 RVG, the ASA clarified that “[d]elivery may include related services such as delivery of placenta or episiotomy/laceration report.”  Providers should ensure that the labor stop time is corroborated by an event that supports the anesthesia stop time reported.
    • The RVG includes a position statement defining the “immediately available” requirement for medically directing providers:

    A medically directing anesthesiologist is immediately available if s/he is in physical proximity that allows the anesthesiologist to return to re-establish direct contact with the patient to meet medical needs and address any urgent or emergent clinical problems.  These responsibilities may also be met through coordination among anesthesiologists of the same group or department.

    Differences in the design and size of various facilities and demands of the particular surgical procedures make it impossible to define a specific time or distance for physical proximity.

    Although the ASA’s position is not binding, it may influence CMS’ interpretation of the requirement as there is no national CMS policy defining “immediately available” in the context of medical direction.

    Anesthesia Crosswalk Changes

    • CPT added 82 new surgical CPT codes.  The ASA’s Crosswalk has recommended crossover anesthesia codes for the new surgery codes in the 2013 Crosswalk.
    • The Crosswalk also includes 141 revised crossover codes, and 75 revised alternate crossover codes.

    Billing software should be updated to include these additions and revisions.

    National Correct Coding Initiative (NCCI)

    CMS’ NCCI facilitates proper payments by applying prepayment edits to claims.  These edits are publicly available fromwww.cms.gov.  The NCCI also contains general billing and coding guidance.  In 2013, the NCCI was revised to address the appropriateness of billing pain blocks with certain types of anesthesia.

    The NCCI states

    Under certain circumstances an anesthesiologist may separately report an epidural or peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain management when the surgeon requestsassistance with postoperative pain management. An epidural injection (CPT code 623XX) for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection.

    A peripheral nerve block injection (CPT codes 64XXX)for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural or peripheral nerve block injection (code numbers as identified above) administered preoperatively or intra-operatively is not separately reportable for postoperative pain  management if the mode of anesthesia for the procedure is monitored anesthesia care (MAC), moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above.
    . . . .
    An epidural or peripheral nerve block injection (code numbers as identified above) for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered preoperatively, intra-operatively, or postoperatively.

    Pain Coding Updates

    Evaluation & Management Services

    • The 2013 CPT clarifies the differences between new and established patients:

    A new patient is one who has not received any professional services from the physician/ qualified healthcare professional or another physician/ qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years.

    When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician.

    • CPT 2013 revises the descriptors for pain pump refill codes 62370 and 95991.  In 2012, the codes stated “requiring a physician’s skill” which made it unclear with a physician’s assistant (using “physician’s skill”) code report the code.  These codes now include state “requiring skill of a physician or other qualified health care professional.”  Thus, other providers may report the code so long as the service is within the provider’s scope of practice.
    • Chemodenervation code 64612 (facial nerve) now includes “unilateral” in the descriptor.  Modifier 50 should be appended to report bilateral procedures.
    • Chemodenervation code 64613 (neck muscles) can only be reported once per session.  Modifier 50 should not be appended for bilateral procedures.
    • There is a new chemodenervation code, 64615, for chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves.  The code includes “bilateral” in the descriptor because it is almost always performed bilaterally; therefore, it should only be reported once per session.  CPT does not address how to report the service when performed unilaterally.
    • Nerve conduction and H-reflex study codes 95900-95936 were deleted and replaced by codes 95907-95913.  The new codes are grouped by type of study and the numbers of studies performed.  The introductory notes state “each type of nerve conduction study is counted only once when multiple sites on the same nerve are stimulated and recorded.  The numbers of these separate tests should be added to determine which code to use.”


    Because of the transition from ICD-9-CM to ICD-10-CM diagnosis codes, there were no new, revised, or deleted codes with the October 1, 2012 release of ICD-9-CM.  The effective date for ICD-10-CM is October 1, 2014 dates of service.

    In preparing for ICD-10-CM, the ability of billing programs to store and report (as needed) both ICD-9 and ICD-10 codes should be evaluated.  Billing programs should also be evaluated to determine whether the format of ICD-10 codes can be accommodated; the impact on reports; and if there is adequate storage capacity to enable dual coding. In addition, coders and providers should be educated regarding ICD-10 coding and documentation at least 6 months prior to implementation in order to decrease the impact on productivity.

    In quarter three of 2013, Medac will release its ICD-10 documentation webinars for providers.  One webinar will cover general and common ICD-10 coding and documentation for anesthesia and pain providers.  Each group will also receive an ICD-10 webinar that is customized to address ICD-10 documentation issues based on the group’s patient population and common procedures/diagnoses reported by the group.

    Medicare Conversion Factors

    For services rendered during 2013, the American Taxpayer Relief Act of 2012 provides for a zero percent SGR update.  The 2013 Medicare conversion factor for non-anesthesia services (e.g., blocks, lines) 2013 is $34.0230.  The unadjusted national anesthesia conversion factor is $21.92, a slight increase from $21.52 in 2012 due to practice expense increases.

    Due to the Budget Control Act of 2011 (sequestration), CMS announced that effective with dates of service on April 1, 2013, all Medicare fee-for-service (parts A and B) payments will be reduced by 2 percent.  The cuts apply to the Medicare payment amount and do not affect beneficiary payments for deductibles and coinsurance.

    Physician Quality Reporting System (PQRS)

    CMS’ PQRS program uses incentives and payment adjustments (penalties) to encourage reporting of quality information by eligible professionals.  In 2013 and 2014, the incentive payment is 0.5% of Medicare allowable payments.  In 2015, a 1.5% payment adjustment will be applied for eligible providers who fail to report satisfactorily during calendar year 2013.

    Obtaining the Incentive

    The criteria for obtaining the incentive via claims-based reporting are summarized below.

    For information regarding EHR registry and reporting, see http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/EducationalResources.html.

    Avoiding the Penalty

    The criteria for avoiding the penalty are easier to satisfy than the criteria for obtaining the incentive.  These criteria are summarized below for providers reporting as individuals and groups that have selected the group reporting option:

    CMS PQRS Updates for 2013, February 2013.

    Anesthesia & Pain PQRS Measures

    There are no new measures for anesthesia, and no measures have been deleted for anesthesia.  Warming/temperature, CVP sterile technique, and prophylactic antibiotics are still applicable measures to anesthesia.  If all three measures apply, anesthesia providers should report on all three measures.

    Pain providers should note that successful reporting of anesthesia measures does NOT exempt pain providers from reporting applicable pain measures.  Several measures, such as “current medications,” “BMI screening,” and “pain assessment” may be applicable.  Failure to satisfactorily report applicable pain measures in 2013 will result in a 2015 payment penalty.  In addition, if an anesthesia group and pain group share the same tax identification number, failure of a pain provider to report applicable quality measures will not only result in a penalty of the provider’s claims as a pain provider, his or her anesthesia claims will also be penalized.

    Maintenance of Certification Incentive Program


    On April 11, 2013, CMS announced that physicians may receive an incentive of 0.5% (in addition to the PQRS incentive) by working with a Maintenance of Certification entity and by completing the following:

    • Satisfactorily submitting data, without regard to method, on quality measures under Physician Quality Reporting, for a 12-month reporting period either as an individual physician or as a member of a selected group practice.


    • More frequently than is required to qualify for or maintain board certification:
      • Participate in a Maintenance of Certification Program and
      • Successfully complete a qualified Maintenance of Certification Program practice assessment.

    Qualified Entities

    CMS has vetted the following entities and deemed them qualified to administer Maintenance of Certification programs that meet the criteria of the incentive program; however, CMS does not guarantee that these programs meet the incentive criteria:

    American Board of Allergy and Immunology
    Phone: 215-592-9466
    Email: abai@abai.org
    Website: www.abai.org 
    All Specialties and Sub-Specialties are qualified.

    American Board of Dermatology
    Phone: 313-874-1090
    Email: abderm@hfhs.org
    Website: www.abderm.org
    All Specialties and Sub-Specialties are qualified.

    American Board of Emergency Medicine
    Phone: 517-332-4800
    Email: abem@abem.org
    Website: www.abem.org 
    The primary certification in Emergency Medicine is qualified.

    American Board of Internal Medicine
    Phone: 215-446-3500 or
    Toll-free: 800-441-ABIM
    Email: request@abim.org
    Website: www.abim.org
    All Specialties and Sub-Specialties are qualified.

    American Board of Neurological Surgery
    Phone: 203-397-2267
    Email: abns@tmhs.org
    Website: www.abns.org 
    All Specialties and Sub-Specialties are qualified.

    American Board of Nuclear Medicine
    Phone: 314-367-2225
    Email: abnm@abnm.org
    Website: www.abnm.org 
    All Specialties and Sub-Specialties are qualified.

    American Board of Obstetrics and Gynecology
    Phone: 214-871-1619
    Website: www.abog.org 
    All Specialties and Sub-Specialties are qualified.

    American Board of Ophthalmology
    Phone: 610-664-1175
    Email: moc@abop.org
    Website: www.abop.org 
    All Specialties and Sub-Specialties are qualified.

    American Board of Optometry
    Phone: 314-983-4244
    Email: info@abopt.org
    Website: www.abopt.org
    All Specialties and Sub-Specialties are qualified.

    American Board of Podiatric Medicine
    Phone: 310-375-0700
    Email: MOC@abpmed.org
    Website: www.ABPMed.org
    Podiatric Physicians Certified in the Specialty of Podiatric Orthopedics and Primary Podiatric Medicine are qualified.

    American Board of Podiatric Surgery
    Phone: 415-553-7800
    Email: moc@abps.org
    Website: www.abps.org
    All Specialties and Sub-Specialties are qualified.

    American Board of Radiology
    Phone: 520-519-2152
    Email: abrmocp@theabr.org
    Website: www.theabr.org 
    All Specialties and Sub-Specialties are qualified.

    American Osteopathic Association
    Phone: 312-202-8266
    Email: certification@osteopathic.org
    Website: www.osteopathic.org
    The following boards are qualified: American Osteopathic Board of Internal Medicine, American Osteopathic Board of Obstetrics and Gynecology, American Osteopathic Board of Pediatrics, American Osteopathic Board of Radiology.



    After selecting a sponsoring organization for the Maintenance of Certification Program Incentive, you must more frequently than is required to qualify for or maintain board certification status:

    • Participate in a Maintenance of Certification Program for a year, and

    MOC programs must require a provider to

    1. Maintain a valid, unrestricted medical license in the United States;
    2. Participate in educational and self-assessment programs that require an assessment of what was learned;
    3. Demonstrate through a formalized, secure examination, that the physician has the fundamental diagnostic skills, medical knowledge and clinical judgment to provide quality care in their respective specialty; and
    4. Successfully complete a qualified Maintenance of Certification Program practice assessment.

    * An eligible professional is required to participate more frequently than is required to maintain board certification in at least one of the first two parts (Part 2 – 3).  Entities may interpret “more frequently” differently.

    • Successfully complete at least one Maintenance of Certification Program practice assessment for such year that includes a survey of patient experience with care.

    The provider must complete a practice assessment for each year of participation in the program.

    Maintenance of Certification Program entities are responsible for submitting 2013 information by February 28, 2014 on behalf of physicians.

    By mid-2013, a final list of qualified MOC entities will be available at


    American Board of Anesthesiology

    Currently, the ABA’s MOC program does not meet the requirements necessary to qualify for the incentive.  In 2011, the ABA evaluated the CMS MOC proposed rule and determined that the costs of implementation exceeded the potential increase in patient quality and reimbursement:

    Based on its understanding of the current CMS requirements, the ABA does not believe that the additional requirements for the MOC bonus will have a sufficient impact on patient care, nor will the reimbursement bonus justify the additional time and resource burden on its diplomats. . . . Accordingly, the ABA does not intend to submit an application for CMS approval of an ABA MOC-PQRS program in 2011. Moreover, some components of the just-released CMS requirements are not in place for 2011 (e.g., a registry for submitting data, and a patient experience of care survey). As a result, the ABA does not intend to submit an application for CMS approval of an ABA MOC-PQRS program in 2011. The ABA projects that the cost of fulfilling the “more frequently” requirement will far exceed the financial value of the 0.5% incentive payment.

    Physicians certified in specialties other than anesthesia should review the qualified entities list above to determine whether the incentive can be obtained through an entity other than the ABA.

    CRNAs & Non-Physician Practitioners (NPPs)

    The MPFS final rule expands coverage of services that can be provided by NPPs. Specifically, the final rule permits payment by Medicare to certified registered nurse anesthetists (CRNAs) for all services that they are permitted to furnish under state law. This change will allow Medicare to pay CRNAs for services to the full extent of their state scope of practice. CRNAs will be reimbursed at the same rate as physicians.  In addition, nurse practitioners, physician assistants, and other NPPs can now be paid by Medicare for ordering portable x-rays.

    Value-Based Payment Modifier

    The Affordable Care Act mandates that by 2015 CMS must apply a “value modifier” to payments made under the Medicare Physician Fee Schedule (MPFS).  The value modifier allows for the consideration of both cost and quality in calculating payments for physicians.  The intent is to shift the payment methodology from one that rewards volume to one that rewards quality: “common sense incentives will improve the care that beneficiaries receive; physicians with higher quality and lower costs will be paid more, and those with lower quality and higher costs will be paid less.” Medicare Physician Fee Schedule, 2013.

    In 2015, physicians groups of 100 or more eligible providers (which includes anesthesiologists, CRNAs, PAs, NPs, etc.) under a single tax identification number will be subject to the value modifier based on their performance in 2013.  In 2017, the value modifier will be applied to all Medicare-participating physicians.  The value modifier will only be applied to physician payment (not allowed) amounts; however, the total number of eligible professionals will be used in determining applicability of the modifier in 2015 to groups of 100 or more eligible professionals.   The overall approach is to base payments PQRS quality data; therefore, even if the value modifier does not currently apply to a particular provider or group, all providers are groups are encouraged to report under PQRS.

    For groups of 100 or more eligible professionals, must follow complete 3 steps in 2013.

    Participate in PQRS

    First, the groups must participate in PQRS in 2013.  These groups must self-nominate/register during one of two time periods, either during the first period from December 1, 2012 to January 31, 2013 or during a second period from July 15 to October 15, 2013.  In addition, the group must select a PQRS group practice reporting option (GPRO) (web interface, CMS-qualified registry, or Administrative Claims option).   A group that self-nominated during the first period will be able to change its PQRS reporting mechanism during the second period.  CMS will use the quality data provided via the GPROs (e.g., registries, claims) to calculate the value modifier.

    NOTE: Groups whose physicians participate as individuals under the PQRS myst register as a group and elect the Administrative Claims reporting mechanism by October 15, 2013.


    Second, the groups must determine whether to elect quality-tiering by October 15, 2013.  The quality-tiering model compares the quality of care composite with the cost composite to determine the value modifier.  Comparisons are made based on quality of care composite scores and the cost composite scores.


    Finally, the group must report at least one measure in 2013 if the group selected the registry or web interface reporting option.

    Impact on Payments

    If a group elects quality-tiering, the value modifier could result in an upward, downward, or no payment adjustment.  Groups of 100 or more eligible professionals who do not elect quality-tiering will avoid a 1 percent value modifier penalty if they self-nominated and reported satisfactorily on PQRS measures.  Groups of 100 or more eligible professionals that do not self-nominate/register as a group and reported at least one measure or selected the administrative claims option as a group, a 1 percent payment reduction will be applied to the group’s physician payments in 2015.

    For more information on the value-based payment modifier and its associated cost and quality measures, see:


    Electronic Health Records (EHRs)

    In 2012, CMS issued its EHR Stage 2 Meaningful Use final rule for the electronic health records incentive program.  Under this incentive program, physicians and specific types of facilities can receive up to $44,000 over a five-year period for each participant who meaningfully uses a certified EHR.  Until last year it was unclear whether anesthesiologists were eligible for the incentive.  CMS clarified that, yes, anesthesia providers are eligible providers for the incentive . . . and the penalty in 2015.

    CMS offered a temporary reprieve for providers such as anesthesiologists who are often not in a position to directly control the implementation of EHRs.  The Stage 2 final rule created a hardship exemption that is determined annually and automatically based on a physician’s specialty designation under the Provider, Enrollment, Chain and Ownership System (PECOS). If a physician is registered in PECOS with a specialty of anesthesia (designation 05), then the physician is automatically exempted from the penalty for up to five years; however, CMS could change the exemption, its criteria for eligibility, and duration before the five-year exemption period is exhausted.

    Office of Inspector General Target Areas

    Each year the OIG releases a work plan that identifies target areas for review.   The following excerpts from the OIG’s 2013 Work Plan may impact anesthesia and pain providers:

    • EHR Meaningful Use – The OIG will review 2011 incentive payments to determine whether providers met the meaningful use requirements for receiving the incentive.
    • Review of Error-Prone Providers – The OIG is using CMS’s Comprehensive Error Rate Testing (CERT) Program data to identify error-prone providers over a 4-year period and will conduct medical reviews of claims.
    • Mailboxes – Program Integrity– Improper Use of Commercial Mailboxes (New). The OIG will determine the extent to which Medicare Part B providers and suppliers had practice locations that matched commercial mailbox addresses in 2011. Medicare providers and suppliers are required to establish physical business facilities of adequate size and with permanent, visible signs and must provide CMS with specific street addresses (not mailboxes) recognized by the U. S. Postal Service. Recent evidence suggests that individuals attempting to defraud Medicare may be using mailbox rental services to evade enforcement of this requirement, as commercial mailbox services provide a recognized street address without a mailbox number.
    • Anesthesia Services —Payments for Personally Performed Services (New).  The OIG will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. The OIG 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 anesthesia procedures by an anesthesiologist. The QK modifier limits payment at 50 percent of the Medicare-allowed amount for personally performed services claimed with the AA modifier. Payments to any service provider are precluded unless the provider has furnished the information necessary to determine the amounts due. (Social Security Act, §1833(e).) (OAS; W-00-13-35706; various reviews; expected issue date: FY 2013; new start).
    • Physicians and Other Suppliers–Noncompliance With Assignment Rules and Excessive Billing of Beneficiaries – The OIG will review the extent to which physicians and other suppliers fail to comply with assignment rules and determine to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare.  Participating Medicare physicians may receive direct payment from Medicare but cannot bill the beneficiary more than the amount specified by Medicare (usually 20% of the allowable).
    • Physicians-Place-of-Service Coding Errors – The OIG will review claims to determine whether the appropriate place of service (e.g., office, outpatient, etc.) was reported.  Medicare pays a higher amount to physicians for services performed in the office setting.
    • Evaluation & Management Services – The OIG will review 2010 claims to determine whether E&M (visit) codes were accurately reported and supported by documentation.  Medicare has identified an increase in the number of medical records with identical documentation across services.  Identical documentation, or cloning, could be seen as attempt to defraud.
    • Local Coverage Determinations-Impact on Physician Fee Schedule, Services, and Expenditures – The OIG will determine how Medicare Local Coverage Determinations (LCDs) affect payment for items and services and assess CMS’s efforts to adopt new national coverage decisions as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.  This means there may be a trend toward national standardization of coverage policies (e.g., some contractors have policies requiring certain diagnoses for MAC).
    • Medicaid Overpayments – The OIG will be reviewing whether providers owe Medicaid refunds for overpayments on claims.