ASA comment letter to CMS regarding Version 5010

October 15, 2008

Mr. Kerry Weems
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-0009-P
P.O. Box 8014
Baltimore, MD 21244-1850

Re: Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards

File Code: CMS-0009-P

Dear Mr. Weems:

The American Society of Anesthesiologists (ASA) appreciates the opportunity to comment on the Proposed Rule cited above. One of the changes proposed for implementation in Version 5010 of the electronic claims standards is of grave concern to our specialty. Specifically:
“Version 5010 only allows the reporting of minutes for anesthesia time, ensuring consistency and clarity across transactions. Version 4010/4010A lacks consistency in allowing for the reporting of anesthesia time, in either units or minutes. This inconsistency creates confusion among providers and plans, and frequently requires electronic or manual conversions of units to minutes or vice versa, depending on a health plan’s requirement, and is especially complicated when conducting COB transactions with varying requirements among secondary or tertiary payers.”
We would like to remind CMS that this same suggestion was put forth in 2002 when the addendum to Version 4010 was under consideration. ASA raised objections to that proposal via our June 28, 2002, comment letter to CMS and through the Designated Standards Maintenance Organizations (DSMO) process with the end result being that the change was not accepted and the ability to report anesthesia time in either minutes or units was maintained.

The concerns we raised at that time remain valid today. As stated in our June 28, 2002, letter to CMS:
Although Medicare requires total minutes, most participation agreements with private payers are premised on the reporting of time units. Forcing payers and providers to use minutes instead will effectively impose Medicare’s fractional unit approach on all payers. This in turn will cause an avalanche of appeals from providers whose contracts or standard practice define time units as “each 15 minutes or fraction thereof” or as “15 minutes, with shorter increments of time rounded up if they exceed 8 (or 10, or 5) minutes.” In the latter example, payers will lose the ability to round down and anesthesia providers will lose the ability to round up. Future contracts will be negotiated with a requirement that the payer round appropriately from the total number of minutes reported. Currently, anesthesia practices themselves perform the rounding and are accustomed to submitting claims that are consistent with the particular payer contract. If payers must begin to divide minutes by various contracted unit denominators (e.g., 15, 10, or 12) and then round according to different contract requirements, errors are bound to occur, resulting in another avalanche of appeals.
The proposal put forth by the Accredited Standards Committee X12 (ASC X12) will not streamline or add efficiency and/or cost savings to the submission and processing of claims for anesthesia care. Instead, it will introduce a host of new concerns and complications and we urge the agency, in the strongest possible terms, not to impose the change.

Recognizing the reality that CMS operates under varied environmental pressures, and that ASA opposes such a move, if CMS ultimately decides to implement the proposal as written and disregard ASA’s position, ASA strongly urges CMS to postpone the proposed implementation date of April 1, 2010, for this portion of the 5010 and implement it in a future addendum. ASA recently conducted a survey of a small sample of our membership and found that the overwhelming majority of members surveyed have contracts with payers that provide for rounding, and thus, would be impacted by the proposed modification. These contract arrangements are as common now as they were in 2002. Given the extensive administrative burdens for anesthesia practices and payers associated with updating record systems, renegotiating payer contracts, and modifying payment systems, coupled with the potential reality of simultaneously converting to the proposed ICD-10-CM system, we believe a delayed implementation of this specific change is justified.

We would be happy to work with CMS to identify a date that would allow adequate preparation time for this transition. We note that CMS has previously reviewed our concerns and found them compelling and legitimate.

The proposal, if adopted by CMS, would change payment policies, payment contracts and payment amounts. Electronic claims standards are meant to implement a process – they are not intended to drive it. X12 should be encouraged to work with applicable specialty societies when considering changes of this sort. ASA supports efforts to increase efficiency and reduce the cost of health care administration but we strongly urge the modification of Version 5010 to allow for reporting of anesthesia time in either units or minutes.

Thank you very much for your consideration. Please do not hesitate to contact us if you have questions or need any additional information.

Sincerely,

Jeffrey L. Apfelbaum, M.D.
President
American Society of Anesthesiologists