September 1998
Volume 62 |
Number 9
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PRACTICE MANAGEMENT
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| 'Black Box Edits'
May Allow Medicare to Bounce More Claims |
Karin Bierstein,
Practice Management Coordinator
"Black box edits" are secret third-party payment rules that result
in claim denials based on the particular code or combination of
codes submitted. This concept is as absurd as it sounds. Nevertheless,
commercial insurers have used software incorporating their own
edits to cut costs for some years, and they have resisted physicians'
efforts to learn what may and may not be billed on the grounds
that the software algorithms are "proprietary" or trade secrets.
The Health Care Financing Administration (HCFA) is about to add
500 commercial black box edits to the tens of thousands of edits
already enforced through the Medicare Correct Coding Initiative
(CCI).
CCI Edits and Anesthesia
Anesthesiologists already have ample experience with claims-editing
software. Before the CCI went into effect on January 1, 1996,
ASA sued HCFA in order to prevent the bundling of invasive
monitoring lines with anesthesia services, and HCFA quickly
settled by agreeing to delete the edits that would have paired
codes 36489, 36491, 93503, 36620 and 36625 (as well 95925, 92585,
92280, 95955, 95900 and 95961) with codes 00100 through 01999.
Subsequently, the CCI software distributed to the Medicare
carriers was modified so as to reject all claims for postoperative
pain epidurals (codes 62274, 62275, 62278 and 62279) filed
together with anesthesia codes even if the "separate service"
modifier (-59) appeared on the form. This time, HCFA corrected
the problem without a lawsuit, issuing a memorandum on November
12, 1997, that instructed the carriers to change the software
back.
At or around the same time that the CCI software began
to reject "separate service" claims for epidurals, it also switched
the "correct coding modifier" indicator so as to reject claims
for nerve blocks submitted together with anesthesia codes.
This change came to the ASA Washington Office's attention only
after HCFA had ordered the correction to the epidural edits, and
it was therefore not part of the negotiations that led to the
November 12 carrier memorandum. Discussions with the HCFA staff
responsible for making and unmaking both of these changes, however,
have produced a promise that the CCI software will once again
be fixed. Although nothing is certain until it appears in writing,
by the beginning of 1999, anesthesiologists should be able to
obtain Medicare payment for nerve blocks that constitute, and
are identified as, separate procedures from the anesthetic.
Other changes for the new year are likely as a result
of a set of nearly 13,000 additional code pairs that HCFA has
recommended for inclusion in the 1999 edition of the CCI. The
list of these code pairs has just been distributed through the
American Medical Association (AMA), which will be coordinating
reactions from the various specialty societies. The ASA Committee
on Economics and Washington Office staff will be analyzing the
proposed changes and will keep members posted.
Coming October 1 (Perhaps), the Black Box Edits
Why does HCFA need to purchase additional editing software?
Answer: Congressional pressure has pushed it in this direction,
with several legislators strongly believing that more aggressive
claims-bundling systems will reduce Medicare spending appropriately.
HCFA has announced its intention to begin implementation,
through the Medicare carriers, of 500 new code pairs on October
1. As of August 17, however, HCFA was still in negotiations with
the software vendor, so the deadline may pass without action.
The hang-up appeared to be the vendor's insistence on maintaining
the secrecy of its claims review criteria. In this matter, HCFA
is sympathetic to the physician's point of view. HCFA Administrator
Nancy-Ann Min DeParle testified before a congressional subcommittee
in May that she did not consider black box edits fair and implied
that she would resist their use in the Medicare program.
It is certainly difficult to make any principled arguments
in favor of secrecy. The undisclosed bundling rules are analogous
to unposted highway speed limits enforced through traffic stops
and fines. How would such an enforcement system foster compliance
and contribute to safety? Likewise, how could secret claims-review
criteria, applied through unexplained payment denials, encourage
"correct coding?" Why would it be more cost-effective to force
physicians to appeal, and the carriers to process, rejected claims
over and over until some sort of coding rule can be discerned?
Not only should physicians be told what the rules are,
they should have a role in ensuring that the rules make sense.
The CCI edits in place now reflect a significant amount of input
from specialty societies and AMA; the AMA in particular fought
for a role first for the CPT Advisory Committee and then for the
ad hoc Correct Coding Policy Committee (CCPC). HCFA adopted some
two-thirds of the CCPC's recommended changes in 1996 and, since
then, has responded to some specialty society concerns regarding
improper code pairs, including ASA's concerns. It seems clear
that the consultative process and the involvement of the medical
profession can improve the product and its acceptance.
The AMA is continuing to lobby HCFA to use the CCPC to
analyze the appropriateness of any new claims edit software and
to engage "in a cooperative effort to help educate physicians
about what constitutes correct coding." ASA will strongly support
these efforts.
Which Procedures Are Going To Be "Bundled?"
We need you to tell us. As things stand, neither
HCFA nor the Medicare carriers are going to give advance notice
of new commercially purchased "edits" that preclude payment for
a procedure deemed included (or incompatible) with the other member
of a pair of codes.
HCFA has said that it will provide the carriers with manuals
explaining the rationale for the newly prohibited code combinations,
and that the carriers should use these manuals to help explain
denials to callers. A help desk at the vendor's office will be
available for carrier inquiries. The carriers will also be required
to track denials in order to determine how much money (if any)
the software is saving Medicare. Thus, the carriers will acquire
some knowledge, but there are evidently no plans to share the
information with the physician community.
Although the proposed 1999 CCI edits have already been
disclosed, it is possible that we will miss some anesthesia problems
among the thousands of edits. Your help in identifying new
edits implemented through this vehicle is critical.
Readers may recall that several years ago, ASA fended
off an effort by a commercial claims-editing software system to
bundle monitoring lines with the anesthetic. The vendor in question
has been acquired by the vendor whose product HCFA is now attempting
to purchase. The odds are good that Swan-Ganz and central venous
pressure procedures will turn up on any list of edits affecting
anesthesiology.
To challenge any unreasonable edits, the ASA Washington
Office will need to know exactly what they are. If you begin
to see claims denied because one procedure is deemed included
in the payment for the other, please provide us with the following
information:
- all of the codes (not just procedure names) affected
- the exact language of any explanation appearing on the Explanation
of Benefit (EOB)
- the name and location of the carrier
- the date of the service provided
- any relevant bulletins or notices from the carrier
- answers given by carrier representatives
Please forward the information to Karin Bierstein by e-mail
to <k.bierstein@asawash.org> or by fax at (202) 371-0384.
Include your name and telephone number.
ASA Comments to HCFA Are on the Web Site
Comments filed by ASA on proposed rules published by HCFA in
the Federal Register are available on the ASA Web site.
Two sets are currently posted; the other one will be postedwhen
it is filed:
1. Telemedicine.
As required by the Balanced Budget Act of 1997, HCFA is planning
to pay a consultation fee to the medical expert in a referral
center who provides guidance through an interactive telecommunications
system to the practitioner who is evaluating the patient. This
proposal will permit nonanesthesiologist physicians and nurses
in certain rural locations to obtain the expert advice of anesthesiologists.
There are several problems in the language of the regulations
as drafted, however, prompting ASA to respond in its comment letters.
2. Elimination of facility fees payable to accredited ambulatory
surgical centers for nerve blocks. Proposed changes in the
method of determining which procedures are on or off the ambulatory
surgery center list would result in the elimination of the $314
fee payable to the facility for most of the nerve block codes.
ASA points out that these procedures generally cannot be performed
in private physicians' offices, which means that they will have
to be performed in the hospital or not at all.
3. Changes
to the practice expense component of the Medicare fee schedule.
After years of efforts involving numerous meetings with physicians
and other specialty society representatives, HCFA has proposed
a completely different approach to the measurement of practice
expenses. Overall, there would be a 3.5-percent increase in the
anesthesia conversion factor. Many pain procedures would also
see an increase, but payments for invasive monitoring lines would
be reduced.
Dates Set for Practice Management Conference Next Year
The fifth annual ASA Practice Management Conference
will be held on February 19-21, 1999, at the Renaissance Parc
55 Hotel, San Francisco, California. Plan to register early as
previous conferences have been at maximum attendance. Among the
topics to be addressed are office-based anesthesia, contracts
with other anesthesiologists, with hospitals and with third-party
payers, and nurse anesthesia issues.
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