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December 2001
Volume 65 |
Number 12
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| Changing Local
Medicare Policies: TEE and Endoscopy |
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
In 2001, ASA members in certain Western, Midwestern and Eastern
states persuaded their state Medicare carriers to make important
changes in policies affecting payment for transesophageal echocardiography
(TEE) and anesthesia for endoscopies. Their experiences —
one considerably more contentious than the other — illustrate
the importance and the process of participating in the development
of one’s carrier reimbursement policies.
Local Medical Review Policies (LMRPs)
Individual Medicare carriers, or more narrowly the carrier medical
directors (CMDs), are responsible for ensuring that Medicare pays
only for “medically necessary” services and for preventing
“excessive utilization.” One of their major tools is
the Local Medical Review Policy (LMRP) program, which has been
discussed previously in the “Practice Management” column.
LMRPs set forth the specific conditions under which Medicare-covered
procedures will or will not be payable.
When a carrier decides to restrict coverage of a particular medical
or surgical service because of apparent overutilization, an LMRP
is the appropriate vehicle. LMRPs are also used by carriers who
decide to pay for a procedure, such as epidurolysis, on which
there is no national policy. Regulations require carriers developing
LMRPs to consider “medical literature, the advice of local
medical societies and medical consultants and public comments.”
Carriers must establish Carrier Advisory Committees (CACs) of
practicing physicians representing all major specialties as described
in the Medicare Program Integrity Manual. Draft LMRPs only become
final when they have been presented to the CACs; CACs are only
advisory, however, and they have no veto power. Most CMDs prefer
a collegial and cooperative relationship with their CAC members,
not adversarial encounters.
TEE
Problems with payers who consider TEE when performed by anesthesiologists
to be simply another modality of monitoring, and thus not separately
payable, led to the creation, at ASA’s urging, of a new Current
Procedural Terminology™ (CPT) code in 2000. The new code
(93318) describes TEE in these words:
Echocardiography, transesophageal (TEE) for monitoring purposes,
including probe placement, real time 2-dimensional image acquisition
and interpretation leading to ongoing (continuous) assessment
of (dynamically changing) cardiac pumping function and to therapeutic
measures on an immediate time basis.
The words “for monitoring purposes,” which appeared
as a surprise editorial change, suggested to many payers that
the new code was an attempt to circumvent the principle that the
usual forms of monitoring are included in the base units for the
anesthesia service. A new ASA policy on TEE, adopted by the House
of Delegates in 2001, makes it clear that TEE is not one of the
usual forms of monitoring but rather a “special diagnostic
tool.” TEE “may be required to obtain the most precise
information to guide surgical interventions (e.g., myocardial
revascularization, valvular competence and repair of congenital
heart defects) and to guide pharmacological support and/or fluid
administration in the perioperative period.”
Meanwhile, Medicare carriers continued to adopt LMRPs declaring
that TEE performed by anesthesiologists was a bundled service.
In the summer of 2000, Noridian Mutual Insurance Company, which
had recently taken over contracts to administer the Medicare program
in 11 Western states (AK, AZ, CO, HI, IA, NV, ND, OR, SD, WA,
WY), announced point blank that it would not pay anesthesiologists
for TEE on the grounds that monitoring was included in the anesthesia
service.
Members of the Society of Cardiovascular Anesthesiologists (SCA)
Committee on Economics sought ASA’s help in confronting the
new Noridian policy. ASA’s own Committee on Economics and
Washington Office staff contacted various Noridian carrier medical
directors to urge adoption of a more discriminating payment policy.
We also called upon the lone anesthesiologist serving as a CMD,
Michael K. Rosenberg, M.D., of Wisconsin Physician Services (WPS).
Dr. Rosenberg, who was new to his position, discovered that a
very restrictive policy was already in place in his own state
of Michigan as well as in the other three WPS states (IL, MN,
WI).
Several SCA committee members had already worked with their own
CMDs to develop LMRPs that covered TEE when performed for diagnostic
purposes by an appropriately credentialed anesthesiologist. Those
LMRPs were presented to Dr. Rosenberg and to the Noridian CMD
who took the lead on the TEE issue, Richard Whitten, M.D. Dr.
Whitten and especially Dr. Rosenberg engaged in a months-long
review and dialogue with ASA and SCA representatives as well as
with their own advisors. In September, both WPS and Noridian presented
new draft LMRPs to the CACs in the 15 states in their respective
jurisdictions.
The two draft LMRPs both recognize intraoperative TEE as a separate
procedure, although their approach is radically different. The
WPS draft would allow payment when the TEE “is expected to
alter the anatomy or function of the cardiac or thoracic structure”:
1. If the evaluation of cardiac function and/or thoracic structures
is necessary for the safe conduct of anesthesia or surgery.
2. If the surgical technique will be affected by the intraoperative
TEE findings, thus assisting in surgical management decisions.
3. If thoracic structures and/or cardiac function were not adequately
evaluated preoperatively AND the information is necessary for
the safe conduct of anesthesia and surgery.
Additionally, the patient must have a condition corresponding
to one or more of 100-plus listed ICD9-CM diagnosis codes. The
draft policy applies to all of the echocardiography CPT codes
(93312-93325 and 93950), but it specifically excludes the new
CPT code 93318 for intraoperative TEE, indicating that anesthesiologists
who perform the service intraoperatively should use the older
code, 93312. The two codes differ principally in that 93312 explicitly
requires the preparation of a report. This requirement is a concomitant
of the service in any event.
The Noridian approach is simpler. It will cover 93318 as long
as the patient has an appropriate diagnosis, identified by ICD9-CM
code, and the anesthesiologist records the interpretation. The
two codes, 93312 and 93318, have been assigned the same number
of relative value units and will generate the same payment amount.
The draft Noridian and WPS LMRPs are open for public comment
as of this writing and will become final shortly. The carriers
will make the appropriate announcements. Anesthesiologists in
states where carriers still bar reimbursement for TEE (e.g., OH,
TX, DC) may wish to use the two new LMRPs as a basis for discussing
changes.
Endoscopy
Empire Medicare Services, a New York carrier, began denying coverage
for monitored anesthesia care for gastrointestinal endoscopic
procedures several years ago. This policy was based on a standard
contractor tool, the “focused medical review” (FMR),
which analyzes utilization rates for abnormal patterns. The FMR
in question revealed that few gastroenterologists involved an
anesthesiologist in every endoscopy while the majority provided
their own sedation. Empire concluded that there was no medical
necessity for any type of anesthesia for endoscopies unless the
patient was unstable or had major comorbidities and issued a policy
restricting coverage accordingly.
The anesthesiologists on the Empire CACs, Scott B. Groudine,
M.D., and Steven Schwalbe, M.D., launched an intense campaign
to correct the policy, lobbying the state and federal legislative
and regulatory bodies and seeking public support when the CMDs
proved obdurate. Empire suspended the policy for a year but then
reinstated it. Meanwhile, Empire also had the Medicare contract
for New Jersey and attempted to extend the policy to that state
in late 2000. Ervin Moss, M.D., the CAC anesthesiologist for Empire
in New Jersey, organized public and political pressure in opposition
to the proposed LMRP.
In a Solomonic decision, the New Jersey CMD ultimately added
a new situation justifying MAC for endoscopy to the list that
included “severe, uncontrolled hypertension… acute asthma
… upper gastrointestinal hemorrhage” and several other
conditions: “The presence of an anesthesiologist/anesthetist
may be considered medically necessary in patients undergoing endoscopic
procedures when an intravenous administration of propofol is given.”
Soon thereafter, Drs. Groudine and Schwalbe persuaded the New
York CMDs to cover endoscopy when propofol was used and also when
muscle relaxants were required or “for patients undergoing
an unusually difficult endoscopic procedure or one accompanied
by unusual amounts of pain or discomfort.” The “unusually
difficult/painful” case requires a written report. Interestingly,
the change was made as a simple editorial correction without going
through the LMRP process again.
It is worth noting the parties whom Drs. Moss, Groudine and Schwalbe
involved in their efforts: their state and federal legislators,
the state departments of health and of insurance, state medical
societies, other specialists on their respective CACs and, of
course, the public. Numerous letters from Congress, from state
senators (even though both the federal and state legislatures
are without any real jurisdiction over the carriers) and from
patients contributed to the results. Dr. Groudine feels that his
promise to tell the press that the Empire policy as applied to
dilation of the esophagus in cancer patients, which uses the same
code as endoscopy, meant that the carrier “doesn’t feel
it is medically necessary that cancer patients eat” was particularly
effective.
Conclusion: If your own Medicare carrier proposes or adopts an
unacceptable payment policy, there may be much work ahead. Processes
may be more circuitous than it seems, and decisions may be less
final than you are told. Do not give up.
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Karin
Bierstein, J.D., works with members and committees on regulatory
matters that affect practice management, quality management
and departmental administration, and Medicare/Medicaid issues. |
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