Highest Volumes and Dollars — Anesthesia

In 1999 (CMS takes at least a year to release the data), the most frequently performed anesthetic was for cataract surgery: 1,919,816 out of a total of 9,721,571 anesthesia services, or 20 percent, were for Current Procedural Terminology‘ (CPT) code 00142. Table 1 lists the total number of claims allowed (as opposed to “submitted”) for the top 10 codes.

In all, Medicare spent $1,391,374,257 on anesthesia services in 1999. The single costliest procedure in terms of total spending on anesthesiologists’ claims was anesthesia for a coronary bypass artery graft (CABG, CPT code 00562) for a total of $106,405,941. Cataract surgery was a close second with $100,085,471. The order was reversed when all specialties’ claims were factored in.

Thus CABG costs Medicare more, although the number of 00562 procedures by anesthesiologists is just 17 percent of the number of 00142 claims. Average payment for a CABG was $532.71; average payment for a cataract removal was $88.21. Table 2 identifies the 10 anesthesia procedures on which Medicare spent the greatest total amounts in 1999. Note that the totals include other specialties besides anesthesiology. Medicare spent $36,834 for CABG anesthesia claims submitted by orthopedic surgeons, for example, and $128,127 on internists. This is probably a good illustration of the “dirty data” phenomenon. Overall, the Medicare claims database is reliable, but there is definitely some “noise” in the hundreds of millions of claims that are filed.

Pain Medicine and Other Nonanesthesia Services

Medicare paid $405,662,589 for pain medicine services (CPT codes in the range 62269-64680) performed by all specialties in 1999. Claims submitted by anesthesiologists netted only $110,572,864. For those procedures performed more than 50 percent of the time by anesthesiologists, total spending on our specialty came to $67,885,128. The highest volume pain medicine service performed by anesthesiologists was for “epidural injection of substance other than anesthetic, lumbar or caudal” (the code number reported in 1999 was 62289; it has been superseded by 62311), with 410,316 claims allowed for a total cost of $42,360,479. HCFA allowed a total of 582,481 claims filed by all specialties. Among anesthesiologists, the daily epidural management code 01996 was in second place with 339,116 procedures, and trigger points (20550) came in third with 201,024 claims. More than 102,600 continuous epidural injections (then 62279, now 62319) and nearly 85,000 single-shot epidurals (then 62278, now 62311) were allowed.

Other than the add-on code, the most frequently allowed nerve block was the lumbar facet joint injection (then 64442, now 64475); 55,758 claims were filed by anesthesiologists. Anesthesiologists also performed 35,446 neurolytic injections of the lumbar facet joint nerve.

Among all the other services and procedures performed by anesthesiologists, the placement of a central venous catheter (36489) represented the highest volume. Nearly 340,000 claims were allowed in 1999. We submitted fewer than 2 percent of all the critical care claims paid by Medicare (31,670 for the first hour [99291] and 4,471 for the half-hour add-on code [99292]).

What do the data show about use of the –QZ modifier?

As anesthesiologists became ever more concerned with compliance with Medicare medical direction rules, ASA suspected that many groups would choose to bill all or most care-team services as “CRNA service without medical direction,” using the –QZ modifier. Taking the example of cataract surgery, 6,098,604 cataract anesthetics were performed by anesthesiologists in 1999 (and fewer than 30,000 of these were performed in physicians’ private offices, incidentally). A startling total of 230,000 cataract anesthetics were billed by other physicians. Almost half of the anesthesia services for cataracts were billed with the –QZ modifier. Similar proportions are showing up for other CPT codes. This seems to validate our hypothesis that many anesthesiologists who employ nurses (and are thus able to collect Medicare payments on their behalf) are using –QZ, which pays the full Medicare allowable even when they are in fact supervising the nurses.

It is perfectly understandable that anesthesiologists do not want to risk having a Medicare auditor determine that they did not fulfill perfectly all of the requirements for submitting a “medical direction” claim. Fortunately, CMS is aware of this unforeseen use of the –QZ modifier and knows that the huge majority of anesthesia services continues to involve supervision by an anesthesiologist. It is, however, an unintended use of –QZ, not necessarily an improper one as far as CMS is concerned. CMS has never issued any statement on whether a practice may, or may not, use –QZ for incomplete medical direction.

On the other hand, more and more local Medicare carriers are establishing policies circumscribing the use of the “nonmedically directed nurse anesthetist” modifier so that it does not become the default form of billing. For example, Trailblazer in Texas initially announced that it would disallow the use of –QZ altogether for incomplete medical direction. The carrier medical director tempered his position after discussions with an attorney representing many anesthesia practices and with ASA staff. An official statement was scheduled to appear in the June carrier newsletter indicating that –QZ would be allowed, but that it should be only used as a fallback. Anesthesiologists are expected to aim for full compliance with the medical direction rules since medical direction is the “industry standard.” QZ would apply in the occasional instance where events prevent the anesthesiologist from completing the service that he or she had intended.

In the same vein, the new carrier medical director for CIGNA in North Carolina responded to an inquiry from the same attorney (David Vaughn, Esq.) with the following: “The short answer is that it is acceptable for the CRNA to bill in his/her name when incomplete supervision has been the situation (the seven elements have not been met). That said, I would add a few caveats …. we would not want to see this used as a ‘back door’ to increasing the ratio of nurse anesthetists to anesthesiologists.”

Anesthesia groups using the –QZ modifier for incomplete medical direction should familiarize themselves with their own carriers’ views — and should also recognize that the situation is fluid.

Criminal Conviction for Practicing Medicine With a Nurse’s License

A Texas nurse anesthetist who owned and ran a private nursing clinic at which she performed hypnotherapy and other pain management services had misrepresented herself as a licensed physician, and the state court of appeals recently affirmed the decision of the trial court sentencing the nurse to jail.

According to the evidence, the nurse held a doctor of medicine degree from Mexico and was a certified registered nurse anesthetist in Texas as well as a certified hypnotherapist. In treating a “patient” who carried a concealed microphone and transmitted the conversation to a patrol car, the nurse introduced herself as “Doctor Weyandt” and quite intentionally sought to create the impression that she was a physician. The treatment provided for the shoulder pain alleged was to attach and turn on a peripheral nerve stimulator and increase the electrical current until the “patient” complained and asked her to stop. The nurse also tried unsuccessfully to hypnotize the “patient” and suggested that she drink a specific herbal tea.

Following the visit, police investigators with a warrant found several containers of drugs in the treatment room, including lidocaine, which can only be administered on physicians’ orders.

The appellate court rejected five distinct challenges to the conviction, including unconstitutional vagueness of the statute proscribing the unlicensed practice of medicine. It upheld a sentence involving one year in jail, probated for two years; 100 hours of community service; 21 days in the Harris County jail and requirement that the nurse post a sign at any place of employment stating that she is not a licensed physician.

Crosswalk™ Update

Early copies of the 2001 Crosswalk™ contained a number of links to which the editors have made recent amendments. The following surgical codes correspond to the anesthesia codes (0XXXX) listed here rather than to those which may appear in copies distributed in February.

We identified these codes because Crosswalk™ users contacted us with questions about the changes. We welcome information about other possible errors. It is difficult for the small group of volunteers from the Committee on Economics responsible for the Crosswalk™ to achieve complete accuracy, but every effort is made to clarify and correct any inconsistencies that are brought to our attention. Your alerts, addressed to Sharon Merrick at s.merrick@asawash.org, will be very helpful.

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FEATURES

2001 Annual Meeting

• New Orleans: You'll Be Swamped With Things to Do

• Emery A. Rovenstine Memorial Lecture

• Lewis H. Wright Memorial Lecture

• FAER Honorary Research Lecture
  
  

ARTICLES

• 2001 Annual Meeting Schedule (.pdf file)

• 1,375 Reasons to Attend the Annual Meeting

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