by Justin Vaughn
It is our sincere hope here at Medac that you and your family are enjoying this holiday season. As we look to another new year, it is only natural to wonder what awaits us—both on the personal and professional level. Certainly those of us in the anesthesia industry are aware that, with every drop of the Times Square ball, new rules are suddenly upon us—rules that will affect the way we must bill, code and comply. So, what’s in store for 2016? The following will act to summarize the key changes for the coming year.
The Medicare anesthesia conversion factor (CF) determines how much Medicare pays for each billing unit (base and time). The 2016 national anesthesia CF was originally set to be $22.3309, per the 2016 Medicare Physician Fee Schedule (MPFS) Final Rule. However, according to the ASA, CMS has since revised this CF amount to $22.4426, which still reflects a slight decline from this year’s national anesthesia CF of $22.6093.
CPT Manual Changes
The CPT manual for 2016 contains a couple of changes that could affect anesthesia, as indicated below:
- New Paravertebral Block (PVB) Codes. Three PVB codes are added for 2016, as follows:
- 64461 – initial injection
- 64462 – add-on code for any additional injections
- 64463 – continuous infusion by catheter
The above codes bundle imaging guidance, per the code descriptor. In addition, the CPT manual clarifies that PVB codes are not to be additionally submitted when billing a cervical/thoracic epidural.
- Ultrasound Interpretation. In the Radiology Guidelines section of the CPT manual, the AMA has inserted a new instruction relative to “Written Report(s)” that specifically requires a provider’s signature on the ultrasound (USG) report:
A written report (e.g., handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.
New RVG Comments
There are no new or revised anesthesia codes for 2016 as found in the CPT manual; however, the ASA’s Relative Value Guide (RVG) includes several new parenthetical comments that act to clarify certain anesthesia services. The ASA acknowledges that “italicized comments within the body of the Relative Value Guide are . . . not part of the CPT descriptor.” So, while these parenthetical comments are intended to clarify a particular code from the ASA’s perspective, they do not have the same authoritative heft as the CPT and ICD-10 manuals, according to one healthcare attorney. With that said, here are the RVG comment additions for 2016:
- 00218 – Intracranial Procedures in Sitting Position. The new RVG comments state:
This code may be reported for anesthesia for any intracranial procedure performed with the patient in the sitting position. This code would be reported instead of another anesthesia code.
- 00530 – Pacemaker. The 2016 RVG comments state:
A pacemaker consists of a pulse generator, electronics, a battery and one or more leads. Pacemaker placement includes programming and testing of both lead and generator functionality. Anesthesia management for placement of cardiac implantable electronic devices that involve this level of testing is reported with code 00530.
- 00534 – ICD Implant. The new RVG comments are as follows:
An implantable defibrillator or cardioverter (ICD/C) includes the same physical components as a pacemaker. ICD/C testing includes all pacemaker testing with additional programming and additional active testing of the cardioversion or defibrillator functions. Active testing includes the induction of an arrhythmia with sensing and treatment by the ICD/C device. Anesthesia management for the placement and testing of an ICD/C is reported with code 00534 if the cardioversion or defibrillator functions are tested. If the cardioversion or defibrillator functions are not tested, report anesthesia management with code 00530.
- 00537 – EP Procedures. The new RVG clarifies: “To be used only for electrophysiologic procedures. For testing of an ICD/C see 00534.”
- 00860/00862 – Urinary Tract/Kidney. The new RVG comment for these codes is as follows: “For anesthesia for transurethral cystoscopic procedures, see codes 00910 and 00918.”
- 00872 – Lithotripsy with Water Bath. The ASA clarifies in the 2016 RVG the following: “Use only when patient immersed in water bath. With small water filled drums/cushions, see 00873.”
- 00912 – TURBT. The new comments in the RVG state: “Includes transurethral resection of urinary tract tumors including bladder neck, bladder, ureters and renal pelvis.”
ASA Position Statements
The ASA’s RVG has historically included a wide array of position statements within its pages. However, those statements have been removed from the 2016 edition of the RVG, and are instead retained on the ASA’s website at www.asahq.org. Regardless of their repository, it is important to note that some of these position statements have changed for 2016:
- Post-Op Pain Billing. The ASA provided the following clarification on post-op pain (POP) blocks:
a. Time spent placing a POP block in pre-op prior to the anesthesia start time, or in PACU after the anesthesia stop time, should not be added to the billable anesthesia time, even if sedation is provided for the block.
b. If the POP block is placed after induction and prior to emergence, the placement time does not have to be deducted.
c. The surgeon, and not just the anesthesiologist, may be required by certain payors to document the request for the POP block in order to secure payment. The Correct Coding Initiative (CCI), the CMS agency charged with establishing bundling rules, has indicated that the surgeon must document the reason why post-operative care was transferred to anesthesia. The takeaway here is that anesthesia groups will need to begin asking their surgeons to document the request for the referral of POP care to anesthesia, along with the reason for the referral—especially in Medicare cases.
- Billing TEE Probe Placement. The ASA has clarified that a probe placement code, such as 93313, can only be reported if another physician interprets the TEE. Specifically, the ASA stated in its revised TEE position statement:
This code is only reported by the physician placing the probe if another physician interprets the images and issues a report of the findings, which is reported with code 93314.
It is therefore incumbent upon providers who only place the TEE probe to assure Medac that another physician is performing the diagnostic interpretation and report, for each such applicable case.
ASA Crosswalk Changes
Each year, the ASA revises its Crosswalk—the publication that translates CPT surgical codes into anesthesia (“ASA”) codes. Below is a list of the significant changes for 2016.
- Higher-Paying Crosses
10030. Image guided fluid collection drainage by catheter. Old crosses: 00300, 00400, 00700 and 00800. New cross: 01922/7 units – anesthesia for non-invasive imaging or radiation therapy.
22856/22857. Total Disc Arthroplasty, anterior approach. 00670/13 units has been added as an alternate cross [if the surgical procedure includes segmental or non-segmental instrumentation as defined in CPT or if the procedure includes multiple vertebral segments (minimum of 3 vertebral bodies w/2 interspaces)].
33273. Repositioning defibrillator electrodes. 00400/3 units has been deleted for 2016. New crosses: 00530/4 units or 00534/7 units.
52354 & 52355. Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion or with resection of ureteral or renal pelvic tumor. Old cross: 00910/3 units – anesthesia for transurethral procedures (including urethrocystoscopy); NOS. New cross: 00912/5 units – anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s).
55530. Excision of varicocele or ligation of spermatic veins for varicococele. Old crosses: 00800/4 units – anesthesia for procedures on lower anterior abdominal wall, and 00920/3 units – anesthesia for procedures on male genitalia (including open urethral procedures). New cross: 00860/6 units – anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract.
55540. Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair. Old cross: 00830/4 units – anesthesia for hernia repairs in lower abdomen. New cross: 00840/6 units – anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy.
58958. Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy. Old cross: 00790/7 units – anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy. New cross: 00846/8 units – anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy.
59076. Fetal shunt placement, including ultrasound guidance. Old cross: 00800/4 units – anesthesia for procedures on lower anterior abdominal wall. New cross: 00840/6 units – anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy.
62268 & 62269. Percutaneous aspiration of spinal cord cyst or percutaneous needle biopsy of the spinal cord. Old cross: 00635/4 units – anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture. New cross: 01935/5 units – anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic.
- Lower-Paying Cross
36221 – 36226. Non-selective and selective catheter placement procedures in the thoracic aorta, common carotid or innominate artery, internal carotid artery, subclavian, and vertebral artery including angiography of the extracranial carotid and cervicocerebral arch, when performed. Old cross: 01926/10 units – anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac, or aortic. New cross: 01916/5 units – anesthesia for diagnostic arteriography/venography.
OIG Work Plan
Each year, the U.S. Office of Inspector General (OIG) publishes a work plan that outlines the areas it intends to target over the upcoming 12 months. For 2016, the work plan includes a new anesthesia-related focus:
Specifically, we will review anesthesia services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not “reasonable and necessary.”
This could signal CMS’s attempt to clamp down on anesthesia payments where the underlying surgical procedures were not covered, or alternatively the above excerpt may refer to a new effort to scrutinize the legitimacy of ancillary procedures additionally billed with an anesthesia claim (eg, invasive lines, POP blocks, TEEs, USG, etc.).
In last month’s client alert, I addressed in detail the CMS incentive programs for 2016, based on a review of the 2016 MPFS Final Rule. The key takeaway at that time was that anesthesia was left with only 1 PQRS measure for the claims-based reporting methodology—specifically, Measure 76, sterile technique for central lines/Swans. As a result, we recommended at that time that our clients consider transitioning to a quality clinical data registry (QCDR) as the best alternative to their current reporting model. Since then, we have received confirmation from CMS, by way of legal counsel, that those anesthesia providers who are left with no measures, via claims-based reporting, MUST report using a traditional registry or a QCDR to avoid the PQRS penalty.
For those who do place central lines and wish to stick with claims-based reporting, there has been yet another change to the definition of Measure 76 for 2016. In order to meet the measure threshold, you will need to revise your pre-formulated attestation statement on the medical record so that it captures the following elements: cap, mask, sterile gown, sterile gloves, sterile full body drape, hand hygiene, skin preparation, and, if ultrasound is used, sterile gel AND sterile probe covers.
In addition, there are 3 new cross-cutting (CC) measures in 2016 for those electing to stick with reporting via claims. They are:
- Measure 112 – Breast Cancer Screening
- Measure 154 – Falls (Risk Assessment)
- Measure 155 – Falls (Plan of Care)
Reporting for each of the above CC measures is triggered by evaluation and management (E/M) codes 99201-99215. This code set reflects new or established office/outpatient visits—something anesthesia providers are not likely to bill. If you don’t bill these codes, you can’t report these new CC measures.
As stated in my last alert, anesthesia providers should strongly consider migrating to an anesthesia-specific QCDR in 2016. This will eliminate the need for reporting CC measures and will enable you to capture at least 9 quality measures—a requirement to avoid the 2% penalty in 2018. If you would like information on participating with a QCDR, please contact your Medac practice manager or compliance liaison.
I wish to thank Baton Rouge, La. healthcare attorney David M. Vaughn for providing much of the information reflected in this alert.
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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.