September 2001
Volume 65 |
Number 9
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| |
PRACTICE MANAGEMENT
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| Fees Paid for
Anesthesia Services: 2001 Survey Results |
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
Commercial anesthesia conversion factors (CFs), or unit payments,
have increased modestly since 1999 when we last collected reimbursement
data from ASA and Anesthesia Administration Assembly (AAA) members.
The current national average CF is in the $45-$47 range.
As in our 1997 (September 1997 NEWSLETTER) and 1999 (August
1999 NEWSLETTER) fee surveys, the questionnaire asked for
the CFs used by the practice’s three highest-volume payers.
Table
1 shows the national averages reported in each of the three
surveys.
The CFs are more than $2.30 higher, on average, than the 1999
figures. A small part of this difference is attributable to a
change in the survey questions that permitted us to normalize
for 10- or 12-minute units so that all CFs are on the same 15-minute
scale. For 2001, we have calculated quartiles and not just medians.
The 75th percentile ranges from $50 to $52; the median from $42.50
to $44, and the 25th percentile from $38 to $39.
Table
1 also reveals that the response rate has improved by 50 percent.
This year again we distributed the questionnaire at the February
Conference on Practice Management and to the committees on Economics
and Practice Management, as well as to the anesthesiologists serving
on the Medicare Carrier Advisory Committees. We added the Committee
on Quality Management and Departmental Administration. Most critically,
the AAA helped us collect responses both at its annual meeting
in Scottsdale, Arizona last May and through its electronic discussion
group.
Capitation arrangements: These do not appear to have become
any more common. Six practices reported an average Medicare Per
Member Per Month (PMPM) rate of $5.49, up slightly from the $5.16
figure resulting from six responses in 1999. The average commercial
PMPM rate ($2.12; 11 respondents) is lower than the $2.40-$2.47
1999 average. These changes are insignificant given the very small
samples.
State and regional statistics: Average CFs in New York
have surpassed the Georgia averages and taken the lead:
| NY (7 respondents) |
$62.29 |
$56.11 |
$52.49 |
| GA (8 respondents) |
$60.19 |
$54.50 |
$58.72 |
Texas and South Carolina both report average CFs higher than
the national average. Pennsylvania and California averages are
all lower than $40. The Northeast and Midwestern regions are now
very close, and the West continues to show the lowest reimbursement
levels.
Further details: The complete set of state (Alabama, California,
Georgia, New York, Oregon, Pennsylvania, South Carolina and Texas)
and regional summary statistics and a full description of the
survey methodology are available in Volume 1, Number 2 of the
e-PM Letter, ASA’s new electronic practice management newsletter,
at < http://www.asahq.org/washington/newsletters/e-pmletterv1n2.pdf
>.
Volume 1, Number 1 was published in July and may be found at
<http://www.asahq.org/washington/newsletters/e-pmletter.pdf>.
Readers may subscribe to a distribution list and will be notified
automatically by e-mail when subsequent issues are posted for
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Benchmarking Productivity
The ASA Committee on Practice Management has been working in
conjunction with the Anesthesia Administration Assembly (AAA)
on several benchmarking surveys. The results of the committee’s
first survey are shown in Table
2. The committee’s primary objective was to generate
data that could be used by the ASA membership as basic guidelines
regarding O.R. case volumes, physician work hours and vacation
weeks for both academic and private practices.
David Fugate, M.B.A., AAA liaison to the committee, and William
Montgomery, M.D., committee member, led the project. Mr. Fugate
reports:
In August of 2000, we sent a one-page survey to all AAA members
(approximately 575) requesting general information based on 1999
year-end statistics. Within two weeks, we received 108 responses,
or an 18.8 percent return. Eighty-two of our respondents were
in private practice and 26 were in academic groups. Eighty-five
groups (78.7 percent) were primarily practicing in a care-team
setting while 23 (21.3 percent) were practicing physician-only.
There were 2,632.9 physician full-time equivalents (FTEs) represented
in this data, or 24.4 FTEs per group. This is approximately 10
percent of the ASA active membership.
The survey reflected an average of seven weeks’ vacation
per physician annually with a range of four to 12 weeks. In addition,
each physician worked, in-house, an average of 52.1 hours per
week.
The committee attempted to obtain case volumes as well. After
lengthy discussions, we agreed that the cleanest and most consistent
data would be to request anesthesia cases only, i.e., “those
cases where there was the induction of partial or complete loss
of sensation, with or without loss of consciousness, by the administration
of anesthetic agents by injection and/or inhalation for medical-surgical,
obstetrical and certain diagnostic procedures.” We specifically
asked that the respondents exclude statistics associated with
chronic and acute pain, critical care and all invasive monitoring
lines. The total number of cases reported was 2,605,426, or 24,124
cases per group. Analyzing case volumes further, cases performed
per physician ranged from 599/FTE (academic-physician-only settings)
to an average of 1,385/FTE (private practice-care-team settings).
The ASA Committee on Practice Management, encouraged by the
results of our first survey, decided to submit an additional survey
to the AAA members. The second survey was sent out in June 2001
and also addressed productivity, this time focusing on nurse anesthetists
and anesthesiologist assistants. We hope to review our results
at the ASA Annual Meeting in New Orleans and publish our findings
shortly thereafter.
Medicare Clarifies When You May Bill for Preoperative Visits
and Tests
Anesthesiologists may bill Medicare for “medically necessary”
preoperative visits and tests. The Centers for Medicare &
Medicaid Services (CMS), formerly known as HCFA, recently issued
an update to the Medicare Carrier Manual clarifying that “medical
preoperative examinations performed by, or at the request of,
the attending surgeon are payable if medically necessary”
if fully documented and supported by the appropriate diagnostic
(ICD-9) codes as well as the ICD-9 codes for preoperative services
(V72.81-V72.84).
Your documentation must show how the specific visit for which
you are billing separately differs from the usual preanesthesia
evaluation. Also, the requirements for the level of Evaluation
and Management (E&M) code chosen must be satisfied. Table
3 sets forth the differences between the separately payable visit
and the visit that is included in the anesthesia base units.
| Table
3. Billable Preoperative Visits and Non-Billable Routine
Preanesthesia Visits |
| Preoperative E&M Service
|
Routine Preanesthesia
Exam and Evaluation |
| Specifically requested by
attending surgeon |
Performed on all patients
receiving anesthesia |
| Medical necessity must be
supported by ICD-9 code |
Included in anesthesia base
units |
| Documentation must support
level of service and surgeon’s request |
ASA Standards approved by
House of Delegates
www.asahq.org/Standards/02.html |
|
Rules for consults must be met in order to bill 99241-99245
or 99251-99255
|
Joint Commission on Accreditation
of Healthcare
Organizations standards have been defined
(these include PE.1.8.1, PE.1.8.2, PE.1.7.3 and TX.2.1) |
|
The update notice also states that preoperative tests (e.g.,
electrocardiograms) ordered by or at the request of the physician
performing the preoperative visit are payable if medically necessary.
Some local Medicare carriers have adopted policies denying or
severely restricting the medical necessity of such tests, and
it is not clear what effect the CMS clarification will have on
such policies. If you are having difficulties with your own carrier,
you should contact your representative on the Carrier Advisory
Committee. The list of representatives is available from m.omar@asawash.org.
Additional information on the CMS update appears in ASA’s
newest publication, the electronic practice management letter,
or e-PM Letter. A partial list of topics in the next issue appears
in the box below.
|
e-PM Letter,
Volume 1, Number 2
Topics
|
| • Fee Survey Results (complete national, regional
and state summary statistics) |
| • AAA Contribution: Benchmarking Anesthesiologists’
Productivity (with links to raw data spreadsheets) |
| • Criminal Sanctions for Fraud (Assistant U.S.
Attorney to speak at 2002 Conference on Practice Management) |
| • Critical Care Services Not to Be Included in
Surgeon’s Fee? |
| • Pain Medicine Economics (Government study under
way) |
| • Costs of Billing for Pain Services |
|
Questions and Answers From the Committee on Quality Management
and Departmental Administration (QMDA)
Conscious Sedation
The QMDA Committee, like many others, receives questions from
various members of the anesthesia community. Some of the questions
appear to be of broad general interest, and the committee has
agreed to publish Questions and Answers in the NEWSLETTER
as appropriate. The first set involves the development of a hospital
policy on conscious sedation. The answers were provided by Jerry
A. Cohen, M.D.
Q We are currently revising our
Conscious Sedation Policy and Procedure, and many questions have
come up. I was hoping you could give us some insight with regard
to the new Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) standards. Should location as to where conscious sedation
can be administered be identified in the policy?
A It could be if this is
a special problem for a particular institution, i.e., if there
are known locations in which safe sedation is difficult, or which
are so remote as to delay rescue. In addition, one might restrict
the number of locations while doing a controlled roll-out of the
policy, making sure that each location is functioning before additional
locations are added. That said, it is generally reasonable to
describe the characteristics of an acceptable location for sedation
in terms of minimum acceptable resources needed to meet the policy’s
standards.
Q Should advanced cardiac
life support (ACLS) be a part of credentialing physicians?
A ACLS may be a useful
means initially to demonstrate proficiency with many of the skills
necessary for rescue, but it is not a single substitute for evaluation
of other factors in credentialing. Ongoing quality evaluation
of the physician or other provider in a particular location and
with a particular patient population, i.e., demonstrated safety
in each sedation venue, is also essential. Further, the credentialing
process must also evaluate the adequacy of the provider’s
pre-op assessment, informed consent and ability to predict and
prepare for potential difficulties. Skills at avoiding or initiating
ACLS are as important as resuscitation skills. Also, ACLS deals
with the skills needed to resolve cardiopulmonary/airway problems
from a slightly different perspective than those needed for conscious
sedation. Participation in a continuing education program (in
sedation), with appropriate simulator activities, might be as
good as or better than ACLS.
Q Should specific medications
be listed for use in conscious sedation?
A I prefer to mention the
generic effect of the drugs on cardiac and ventilatory function
and the mechanisms by which these effects are detected and whereby
the dose is titrated to effect in a controlled manner. Included
in this approach is a description of the methods and continuous
nature of monitoring. Occasionally, one might specify a specific
drug that tends to be used in a way that might be problematic,
depending on the context of its use. For example, propofol may
be appropriate for deep sedation in ventilated patients in an
ICU, but not for sedation in a cath lab regardless of the way
it is used. There is almost never a compelling need to describe
the pharmacopia of sedating agents or their dosages. In fact this
temptation is to be avoided because it gives a false sense of
security to practitioners administering the drugs/dosages on the
protocol when they should be monitoring and titrating to effect.
There is a sample sedation policy on the ASA Web site at www.asahq.org/ProfInfo/toolkit/sedmodelfinal.htm.
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