Changing and Ongoing Dynamics
Getting appropriately paid for medical services in this country can be an ongoing challenge. In the first place, the CPT codes are constantly being updated in response to new and changing clinical protocols, and they are the key to payer adjudication. Then there are the payer policies that reflect changing billing patterns; the more a particular code is billed, the more closely utilization patterns and trends are monitored, and the more likely the payer is to lower the payment or restrict payment options. Ultimately, payer policies are supposed to reflect medical necessity guidelines, but these can be somewhat arbitrary.
We always stress the importance of clear and complete documentation to our clients because this is ultimately what it comes down to when we have to appeal a claim. While these are general guidelines that apply to all medical services, getting paid for anesthesia care for chronic pain nerve blocks provides a perfect case study of these interlocking dynamics.
Its Place in Your Practice
Most of our clients are asked to provide anesthesia for various nerve blocks. Usually, this is a courtesy service rather than a clearly defined line of business. It is typically a service requested by a specific chronic pain physician or it is a service provided when a chronic pain patient’s condition would make it difficult to perform the block without anesthesia. Monitored Anesthesia Care (MAC) is the preferred mode of anesthesia in such cases.
For most of our clients, anesthesia for chronic pain blocks represents one to two percent of all cases, although there are some exceptions where this service represents more than 10 percent of all cases. We strongly urge all clients to have a clear understanding of how important this type of service is to their practice.
Our practice managers are often asked by our clients if they are getting paid for this service. The answer is yes at this point in time for most insurance plans, although there are some very notable exceptions, such as Horizon Blue Shield in New Jersey. There tend to be more denials connected with these types of cases than for others, but these denials tend to get resolved through the appeals process, meaning that the client gets paid; it just takes a little longer. In general, payments are consistent with the rates paid by insurers for other anesthesia services.
Bigger Picture Concerns
So, what are the concerns? The future of payment for this service is very uncertain; in fact, we are betting it will be eliminated by most payers within the next few years. We are already seeing insurance plan policies evolve, as per the example below from CIGNA, to reflect ever more restrictive medical necessity guidelines. It may just be a matter of time before CMS (Medicare) adopts similar language.
What do we conclude from all this? Here are a few items to keep in mind:
- Documentation. When billing for anesthesia for nerve blocks, you need to ensure the block is clearly documented, including an indication as to whether it was therapeutic or diagnostic. The use of fluoroscopy must be noted. We cannot accept any blanket statements such as “these procedures are always performed with fluoroscopy.”
- Business Plan. This is no time to be expanding this line of business. The chronic pain specialists requesting this service should be forewarned that the anesthesia practice may have to re-assess its ability to provide this service if payer policies continue to change in a negative fashion.
If you are curious what role anesthesia for nerve blocks actually plays in your practice and what its actual revenue potential is, please contact your Medac account executive who will be happy to provide you a detailed performance review, by payer.