October 1999
Volume 63 |
Number 10
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PRACTICE MANAGEMENT
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| 'Bundling' Invasive
Lines: Anesthesiologists Take on the Payers |
Karin Bierstein,
Practice Management Coordinator
At least three Blue Cross/Blue Shield carriers are denying payment
for invasive monitoring lines on the grounds that these services
are included in the anesthesia fee. The ASA Washington Office
has also learned of one Aetna health plan that has adopted the
same policy. At a minimum, this activity may foreshadow a trend,
and we would like ASA members who experience the "bundling" of
invasive lines to let us know. There are numerous strategies anesthesiologists
may employ, individually and on a coordinated basis.
What the Payers Are Doing
The bundling of central venous pressure and arterial lines
surfaced as a problem last fall in Wisconsin. When Blue Cross
and Blue Shield of Wisconsin and its affiliate, Compcare Health
Services Insurance Corporation (collectively referred to as BCW),
began rejecting claims for those procedures, several anesthesia
groups billed the patients directly. The groups did not have contracts
with BCW that might prohibit balance-billing, nor did state law
prevent collecting from the patient.
The anesthesia groups eventually went to court to obtain
payment. BCW undertook the defense as "indemnitor" for each of
the patients in seven separate proceedings. BCW argued that CVPs
and arterial lines as well as postoperative pain management nerve
blocks and hemodilution were an integral and "usual" part of the
anesthesia service and were compensated through the base units
for the anesthetic. BCW also claimed that both the American Medical
Association and the national Blue Cross and Blue Shield Association
had taken the position that placement of invasive monitoring lines
should not be reimbursed and that many other private payers similarly
bundled these procedures with the anesthetic. BCW denied that
it had adopted a new policy, contending that only inadequate information
systems and "computer logic" had permitted payment of the claims
prior to 1996.
None of these arguments persuaded any of the court commissioners
hearing the cases. All of the court commissioners upheld the anesthesiologists'
right to recover. BCW appealed each decision to the circuit court.
Only one circuit court appeal has been completed to date -- again
supporting the anesthesiologists. It is expected that BCW will
appeal the circuit court decisions to the Wisconsin appellate
courts.
Meanwhile, a handful of other payers are implementing
similar bundling policies; the Blue Cross and Blue Shield companies
in Maryland and in Alabama and an Aetna health maintenance organization
in Colorado are denying claims for all invasive monitoring (including
Swan-Ganz catheters) and, in at least one case, for postoperative
pain services as well.
The Arguments on Both Sides
BCW, as noted above, insists that arterial lines and central
venous lines are necessary components of the anesthesia service
for every coronary artery bypass surgery and that "this kind of
monitoring is basic and inherent to the general anesthesia procedure.
It is the standard of care required and a relatively simple procedure
taking in most cases just a few minutes to perform."
Even if BCW is correct that placing CVP and arterial lines
is the standard of care for bypass surgery and correct that it
does not take more than a few minutes, the CPT™ guidelines
that BCW cites in support of its view in fact recognize monitoring
as a distinct service. According to the Anesthesia Guidelines
appearing on page 37 of the 1999 CPT book, "these services include
the usual preoperative and postoperative visits, the anesthesia
care during the procedure, the administration of fluids and/or
blood and the usual monitoring services (e.g., ECG, temperature,
blood pressure, oximetry, capnography, and mass spectrometry).
Unusual forms of monitoring (e.g., intra-arterial, central venous
and Swan-Ganz) are not included."
Elaborating on this principle, the February 1997 issue
of CPT Assistant, a newsletter published by the
AMA CPT staff, stated that "Basic anesthesia administration services
... include interpretation of noninvasive monitoring such as ECG
(electrocardiography), body temperature, blood pressure, oximetry
(blood oxygen concentration), capnography (blood carbon dioxide
concentration) and mass spectrometry." The article on "Anesthesia:
Coding for Procedural Services" goes on to provide an illustration
of appropriate coding where the anesthesiologist inserts an arterial
line (code 36620) and reports the service on a separate line on
the claim form. Another illustration affirms the separate and
distinct nature of postoperative pain management nerve blocks.
The CPT Assistant uses language very similar to
that of the ASA Relative Value Guide (RVG), according to which:
"The usual anesthesia services included in the Basic Value include
the usual preoperative and postoperative visits, the administration
of fluids and/or blood products incidental to the anesthesia care
and interpretation of noninvasive monitoring." The intent will
be made even clearer in future editions of the RVG.
BCW contends that not only AMA policy, but also that of
the national Blue Cross and Blue Shield Association (which licenses
the independent, individual BC/BS carriers) mandates the bundling
of invasive lines. This claim is inaccurate. There is an optional
Policy Reference Manual available to licensees. The administrative
policy on anesthesia services that has been in effect since May
1997 is ambiguous on the inclusion of invasive monitoring services,
but it is not binding on the carriers unless contracts with employers
require its use.
BCW and the other carriers mentioned above argue that
the basic unit values in the RVG take into account the insertion
of monitoring lines. A review of the history of the RVG by L.
Charles Novak, M.D., chair of the Committee on Economics, has
demonstrated that is not the case. This is noted by Dr. Novak
in a Statement on Invasive Monitoring Procedures that readers
may request from Caroline Coleman in the Washington Office (202)
289-2222; e-mail.
"As the ASA has developed and refined its Relative Value Guide,
placement of invasive monitoring devices has not been factored
in when establishing basic unit values. In fact, the basic unit
values for many anesthesia codes in which invasive monitoring
is now common were established prior to the use of invasive devices,
and have not been changed. Furthermore, inclusion of additional
basic units to account for invasive monitoring in some anesthesia
codes and not in others would make the relative value system inconsistent."
Yet another justification advanced for the bundling policy is
the use of third-party software that identifies CPT codes that
are deemed a component of other codes and that automatically kicks
claims out for denial of payment. One of the health plans using
such software claims that the bundling of invasive lines is a
standard "edit" that the plan has no discretion to change
an assertion that is questionable. Most commercial claims editing
software vendors contend that their edits can be turned on or
off as the client wishes. Blue Cross Blue Shield of Maryland wrote
in a letter to a state senator inquiring on behalf of an anesthesiologist-constituent
that the ClaimCheck™ system that it uses is based on the
CPT "coding criteria," which is manifestly untrue in the case
of invasive monitoring procedures provided to patients undergoing
general anesthesia.
None of the four carriers who has come to our attention
has claimed consistency with Medicare policy. In fact, Blue Cross
Blue Shield of Alabama explicitly disavows following Medicare
policy. ASA's filing of a lawsuit against the Health Care Financing
Administration in 1995 quickly resulted in a settlement agreement
in which the agency agreed not to bundle any invasive lines with
the anesthesia service.
What the Affected Anesthesiologists Are Doing
Anesthesia groups in Wisconsin promptly retained counsel
and began pursuing small claims court actions. Any anesthesiologist
who does not have a contractual or state law impediment (or personal
objection) to pursuing the patient directly may follow this course.
The Wisconsin groups' lawyer is considering bringing a consolidated
lawsuit to compel BCW to change its policy once all seven appeals
to the Circuit Courts have been won.
Wisconsin anesthesiologists also worked with and through
the state ASA component society to obtain state legislation that
would prevent private payers from adopting bundling policies more
restrictive than Medicare's. The following amendment has been
included in the lower-house version of the budget bill that is
currently pending in the Wisconsin legislature:
"An insurer may not deny payment under a disability insurance
policy or group certificate for a medical or surgical service
or procedure on the basis that the service or procedure is an
integral component of a second medical or surgical service or
procedure unless, under Medicare Part B, payment for the first
service or procedure is included in the payment for the second
service or procedure."
In the other states, the anesthesiologists and practice administrators
who have brought the problem to ASA's attention are still formulating
strategies. If appeals within the carriers' own hierarchy fail,
including physician-to-physician discussions with the carrier
medical directors, it will become important to coordinate an approach
with other anesthesiologists whose claims are being rejected.
What ASA Is Doing
Eugene P. Sinclair, M.D., Vice-Speaker of the House of
Delegates and a Wisconsin anesthesiologist himself, has been consulting
with Washington Office staff and serving as an expert witness
in the litigation in his state. ASA members Robert Purtock, M.D.,
and Joseph Bernstein, M.D., have also served as expert witnesses
in the Wisconsin courts. We have provided Dr. Sinclair with documentation
including materials prepared by Dr. Novak. We have also begun
assisting Maryland counsel.
We have involved the AMA's State Medical Society Litigation
Center in the Wisconsin activity and have drawn its interest to
the situation developing in other states. The Litigation Center
is a consortium of the AMA and 45 state medical societies whose
"purpose is to concentrate resources in order to bring lawsuits
of significant interest to organized medicine." The AMA's support
for the Wisconsin litigation is not yet determined, but it may
take the form of funding, of lending the AMA's prestige to the
action or even of sharing its own expertise.
There is much more that we will be able to do and perhaps
much that we will need to do. Our starting point is information.
Please contact your state component society and the Washington
Office if you are encountering private payer bundling policies
similar to those discussed above.
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