October 2000
Volume 64 |
Number 10
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| Obstetric Anesthesia:
Reimbursement Issues |
L. Charles Novak,
M.D. Chair
Committee on Ecnomics
Chaos reigns in the area of coding, billing
and reimbursement for obstetric anesthesia services. Wide variation
exists across the country with regard to Current Procedural Terminology
(CPT) codes used to describe services, methodologies to account
for time during neuraxial analgesia for labor, and reimbursement
formulas for obstetric anesthesia. Among the charges to the ASA
Committee on Economics are monitoring issues related to reimbursement
and the development of procedure codes and relative values for
anesthesia services. This article will describe areas of confusion
and concern, current ASA Relative Value Guide (ASA-RVG) guidance
and future directions relating to billing and payment for obstetric
anesthesia services.
Areas of Confusion and Concern
Coding: Codes specifically developed
for describing obstetric anesthesia services appear in the ASA-RVG
both in the regular numeric listing of codes and in a special
section, "Obstetric Anesthesia." Codes 00955 and 00857
are the only two CPT codes that describe neuraxial analgesia followed
by either vaginal delivery or cesarean section. They are valued
at five and seven basic units respectively, plus time. Since most
computer billing programs are set up to handle only one set of
times per code, a potential problem exists for code 00857. Certain
methods for accounting for time during neuraxial analgesia for
labor involve a discounting of usual time units. When a cesarean
section becomes necessary, there is no way to indicate the point
in time when time units should be given full value (as with any
other surgical anesthetic). In some instances, anesthesiologists
do find that third-party payer systems are counting time at one
or two units per hour right through the cesarean section.
Use of surgical codes with anesthesia modifiers
to describe neuraxial analgesia for labor followed by vaginal
delivery or cesarean section does not adequately describe the
anesthesia service. Descriptors for the codes 59409 and 59514
refer only to vaginal delivery and cesarean section and make no
reference to labor (epidural) analgesia.
Using the code for continuous lumbar epidural
(62319) for labor analgesia is also incorrect. There is no provision
for time associated with this code in the ASA-RVG. Nevertheless,
this is not an uncommon setup in many localities for billing and
payment for labor analgesia.
Code 62311 is appropriate for use when
performing a single-shot spinal containing opiod and frequently
for a low dose of local anesthetic. Theoretically, code 00955
could also be used for this service with a limited number of time
units.
Time Accounting: Traditions have
been built, locality by locality, with regard to accounting for
time during continuous labor analgesia. There seems to be no universally
best way to accomplish the task. Anesthesiologists do have an
ethical obligation to establish policies that are fair both to
themselves and to their patients. Within the realm of fairness,
there are a number of methodologies that can work. ASA's position
on the issue appears later in this article.
Billing and Reimbursement: Because
of the issues related to coding and time accounting, anesthesiology
practices need to pay particular attention to their billing methodology
and the payment policies of the third-party payers with whom they
have agreements. Errors can be costly. For example, a large anesthesiology
group discovered after many years that a third-party payer with
which it contracted had been paying anesthesia time at one unit
per hour during cesarean sections that followed epidural analgesia
for labor. On the flip side, in one state (although Medicaid regulations
provided for discounted time during epidural analgesia), the agency
had been paying anesthesiologists full time units. As governmental
agencies will do, they asked the anesthesiologists to return the
overpayments. A thorough understanding by both anesthesiologists
and payers of reimbursement arrangements surrounding obstetric
anesthesia is an essential element of good practice management.
| "Our
goal is to have order emerge from the chaos that now exists
in the area of coding, billing and reimbursement for obstetric
anesthesia services and thus to make this important medical
care more readily available to patients." |
ASA Relative Value Guide
To assist members with coding and billing,
the ASA-RVG contains a separate section for obstetric anesthesia.
Preceding the code and relative value listings, the following
introductory statements appear:
Unlike operative anesthesia services, there
is no single, widely accepted method of accounting for time for
neuraxial labor analgesia.
Professional charges and reimbursement
policies should reasonably reflect the intensity and time involved
in performing and monitoring any neuraxial labor analgesic.
Methods to determine professional charges
consistent with these principles include:
1. Basic units plus patient contact time
(insertion, management of adverse events, delivery, removal)
plus one unit hourly.
2. Basic units plus time units (insertion through delivery),
subject to a reasonable cap.
3. Single fee.
4. Incremental fees (e.g., 0-2 hrs, 2-6 hrs, >6hrs).
Future Directions
James P. McMichael, M.D., has led a workgroup
within the Committee on Economics in preparing revisions to coding
and relative values relating to obstetric anesthesia. During this
project, he has worked closely with the Board of Directors of
the Society for Obstetric Anesthesia and Perinatology (SOAP).
The revisions have received the endorsement of the ASA House of
Delegates and are ready for presentation to the CPT Editorial
Panel for its approval. The changes may be summarized as follows:
• Codes relating to anesthesia services
in the peripartum period will be grouped and renumbered into
sections of the ASA-RVG and the CPT manual that are specifically
set aside for "obstetric anesthesia. "
• A single code will cover neuraxial
analgesia for labor and planned vaginal delivery. This will
be the only code for which time accounting may vary from standard
methods used for surgical anesthesia.
• Cesarean delivery following neuraxial
labor analgesia will be covered by an add on code with additional
basic units and an understanding that time will be accounted
for as it is for all other surgical anesthesia.
• A series of codes will also cover
the unusual occurrence of hysterectomy either at the time of
cesarean section or immediately following vaginal delivery.
At this time, the Committee on Economics
has not decided whether to publish these changes in the 2001 ASA-RVG.
The coding changes will not appear in CPT before 2002. Publishing
in 2001 would give members a chance to learn the new system and
lobby private third-party payers for its implementation. That
would occur, however, against a background of a mismatch with
CPT. Waiting until 2002, when both publications should match,
would allow for better coordination of educational efforts and
a smoother transition for all concerned parties.
As national medical organizations develop
and promulgate policies related to the economics of medical practice,
they must remain cognizant of the wide variation in medical practice
across our country. Such national policies must therefore remain
somewhat general to allow for local interpretation. When the revisions
relating to reimbursement for obstetric anesthesia are released
for implementation, ASA and its Committee on Economics will make
significant efforts to inform members and third-party payers regarding
their interpretation and use. The committee's goal is to have
order emerge from the chaos that now exists in the area of coding,
billing and reimbursement for obstetric anesthesia services and
thus to make this important medical care more readily available
to patients.
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L.
Charles Novak, M.D., is a practicing anesthesiologist, Wenatchee
Anesthesia Associates, Wenatchee, Washington. He is also the
Director for District 23 (Washington, Alaska). |
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