March 2001
Volume 65 |
Number 3
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PRACTICE MANAGMENT
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| Labor
Epidurals and Billing Methods |
Karin Bierstein,
Assistant Director of Governmental Affairs (Regulatory)
In May 1997, members of the Society for Obstetric Anesthesia
and Perinatology (SOAP) responded to a survey regarding methods
of billing for labor epidurals. The results, reported in the November
1997 NEWSLETTER, showed great variety. Half of the respondents
reported that they used multiple methods, depending on the payer.
Billing actual time subject to a cap was the most common method.
Following review of the SOAP results, the ASA Committee on Economics
added a statement on obstetric anesthesia to the Relative Value
Guide (RVG) that noted: 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:
- Basic units plus patient contact time (insertion, management
of adverse events, delivery, removal) plus one unit hourly;
- Basic units plus time units (insertion through delivery),
subject to a reasonable cap;
- Single fee;
- Incremental fees (e.g., 0 < 2 hrs, 2-6 hrs, > 6 hrs).
There does indeed continue to be considerable variation, according
to another obstetrics anesthesia survey conducted by the Anesthesia
Answer Book (AAB) (United Communications Group, 11300 Rockville
Pike, Suite 1100, Rockville, MD 20852-3030, telephone 877-397-1496)
last year. The following percentages of respondents to the AAB
survey used each of the billing methods listed:
44% Base units plus time (insertion through delivery), subject
to a reasonable cap
19% Base units plus patient contact time (insertion, management
of adverse events, delivery and removal) plus one unit hourly
16% Flat fee
11% Incremental fees
6% Base units plus face time only.
6% Total time from insertion through delivery
Billing for total time with a cap negotiated or self-imposed
is clearly still the dominant method. Flat fees are no more common
than they were in 1997. Twice as many SOAP respondents reported
billing for total time from insertion through delivery, i.e.,
without a cap, but the apparent decrease may reflect very small
samples rather than an actual change.
The AAB survey also asked for the Current Procedural Terminology
(CPT) codes used to bill labor epidurals. Seventy-seven percent
of the respondents cited 00857 (Neuraxial analgesia/anesthesia
for labor ending in a cesarean section) and 00955 (Neuraxial analgesia/anesthesia
for labor ending in a vaginal delivery). Thirty percent used the
general continuous epidural code 62319; 23 percent reported the
surgical obstetric codes with the modifier 7, which denotes type
of service: anesthesia. Nineteen percent of the returned surveys
indicated that Medicaid required the use of its own labor and
delivery codes, and 9 percent reported billing for other codes.
One wonders at the cost of programming so many variations on
both code selection and accounting for time.
On a related subject, there continues to be a lot of confusion
about the appropriateness of using the emergency modifier (code
99140, with 2 base units) in conjunction with anesthesia for labor
and delivery. The RVG defines emergency as a situation in which
delay in treating the patient would lead to a significant increase
in the threat to life or body part. A vaginal delivery or a scheduled
cesarean section would likely not constitute such an emergency.
Neither would the fact that the patient goes into labor at night
or on a weekend. (Note that the definition also doesn’t mention
full stomach conditions, though patient conditions qualifying
as emergencies are most often the clinical justification for administering
anesthesia under such circumstances. In obstetrical anesthesia,
however, this is less often the case, according to Alexander A.
Hannenberg, M.D., of the Committee on Economics.)
When asked about the use of the emergency code for an after-hours
appendectomy, L. Charles Novak, M.D., Chair of the Committee,
once advised by e-mail that a practical way to analyze the applicability
of the modifier was to ask the following question: Does the surgeon
drop everything else he or she is doing to get to the operating
room to get the surgery done? That happens when there is a bad
open fracture, and leaking or ruptured AAA, etc.
Hip Joint Procedures: Correction and Explanation
In the January NEWSLETTER, page 21, the ASA RVG base units for
the two hip joint CPT codes that were revised for 2001 were inadvertently
transposed. The correct ASA RVG units are as follows:
01214 Anesthesia for open procedures involving hip joint;
total hip replacement: 8
01215 revision of hip arthroplasty: 10
Many readers have questioned the difference between the ASA
base units and the Health Care Financing Administration (HCFA)
(i.e., Medicare) base units for code 1214; HCFA allows 10 units
rather than eight. The HCFA value appears in the list of 2001
anesthesia codes and their associated base units received electronically
by the ASA Washington Office, by the American Medical Association
and presumably by the Medicare carriers.
Accordingly, Medicare will be paying for 10 base units for both
codes unless HCFA has amended its file since sending us our copy.
Any private payer that uses the Medicare codes and base units
would allow 10 units as long as Medicare does. Much more commonly,
private payers follow the RVG itself, and since our own valuation
is still eight base units, those payers would allow eight base
units.
Upcoming Practice Management Conferences
1. The sixth annual ASA Conference on Practice Management took
place in La Jolla, California, on February 2-4, 2001. Nearly 300
attended, and an impressive proportion stayed until the very end.
Topics included Pain Management Strategies for a Profitable Pain
Practice, Office-Based Anesthesia, Continuous Quality Improvement
and Internal Benchmarking, Investing in Ambulatory Surgery Centers
and many others suggested by ASA members' questions. The compendium
of monographs is available for $40 from
publications@ASAhq.org.
2. The seventh annual Conference on Practice Management is scheduled
for the first weekend in February 2002, in Phoenix, Arizona. Program
development is now under way, and we welcome your suggestions
for subjects and speakers.
3. On May 20-23, 2001, the Anesthesia Administration Assembly
(AAA) of the Medical Group Management Association (MGMA) will
be holding its annual conference in Scottsdale, Arizona. Breakout
sessions will include such topics as office-based anesthesia,
the results of the survey of hospital contracting first presented
in La Jolla, Putting the Web to Work in Physician Practices, governance
and provider supply and demand. The conference will primarily
educate your administrative staff, but note that there also will
be a physicians' networking breakfast. For a copy of the program
brochure and registration information, contact MGMA at (888) 608-5602.
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Compliance Corner
From questions sent to members of the Committee on Practice
Management:
Q.
Can an anesthesiologist who is medically directing two or
more cases give a lunch break to one of the nurse anesthetists?
A.
No. The anesthesiologist who allows the nurse anesthetist
to leave the operating room would then be personally performing
that anesthesia service. If the anesthesiologist were then
to leave the operating room (patient #1) to monitor one
of the medically directed cases (#2 and #3, hypothetically),
no one would be able to bill for the case in which there
was no anesthesia provider present. More importantly, the
anesthesiologist would be abandoning patient #1. Furthermore,
personally performing anesthesia for patient #1 would not
be an allowable activity in so far as the medical direction
of cases #2 and #3 is concerned.
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