A new resource is now available to assist practices in making sure their billing systems’ vendors are ready to comply with the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA mandated a set of electronic transactions and code sets standards, including important business transactions commonly used in anesthesia practices such as the health care claim, remittance, verification of claim status and others. Pain medicine practices will be interested in the electronic standards for patient eligibility verification, treatment and referral authorizations and certifications.

HIPAA Pointer: Are You A “Covered Entity?” Medical practices are “covered entities” under HIPAA and must adopt these new standards if they fall into either of the following categories: • Those practices that electronically exchange information related to any of the HIPAA “covered” transactions (i.e., you submit health care claims or receive remittances electronically); or • Those practices that pay a third party (clearinghouse or billing service) to submit any of the HIPAA transactions electronically on their behalf. CMS has created a brief interactive process to help you answer the question at <www.cms.hhs.gov/hipaa/hipaa2/support/tools/decisionsupport>.

The deadline was originally October 16, 2002 for practices and health plans (see box titled “Are You A ‘Covered Entity?’”) to begin transmitting only HIPAA-compliant electronic transactions. Legislation extended that deadline to October 16, 2003, for those who submitted timely information on compliance plans to the Centers for Medicare & Medicaid Services (CMS).
Practice tip: If you did not apply for the extension of the deadline, CMS has stated that you “should come into compliance as soon as possible and should be prepared to submit a corrective action plan in the event a complaint is filed against you.” The only way that CMS will know whether you are in compliance is if a private party chooses to file a complaint about your not using the HIPAA standard.

Check Your Vendor on a New Web Site
In collaboration with more than a dozen other medical specialty organizations, ASA has created a Web site <www.hipaa.org/pmsdirectory> designed for the sole purpose of helping members ascertain the HIPAA-readiness level of practice management software (PMS) vendors. This resource offers information on whether the software is capable of creating and transmitting claims or other transactions that meet the HIPAA requirements as well as vendor contact names and numbers.

Vendors post their information directly without charge. There is no cost to physicians or practice administrators who access the site and all the information it contains. Neither ASA nor any of the other sponsoring organizations verify the posted software’s HIPAA-readiness or its quality. They are listed in alphabetical order, and clicking on a vendor will take you to the very brief questionnaire that vendors are expected to complete. There are several safeguards intended to prevent mere advertising, but ASA does not endorse or warrant vendors or their products. The best objective information is whether the vendor has completed third-party testing and certification of the software supporting each of the HIPAA transactions.

Typically many anesthesia practices have been anticipating that their PMS vendors will be providing a “HIPAA-compliant” solution for them. In many cases, this will be justified. A significant number of PMS vendors, however, will be unable to offer practices the necessary solution for the following reasons:

• Some software vendors will be offering appropriate modifications but not in time to meet the deadline;

• Some vendors have made a corporate decision not to offer a HIPAA-compliant solution, but rather will be requiring their customers to go through a particular clearinghouse that they own, and incur per-transaction fees; or

• Some vendors will not be offering any HIPAA-ready solution.

The repercussions of any of the above scenarios could have a detrimental impact on the cash flow of an anesthesia or pain medicine practice. Therefore, it is important that physicians and their practice administrators take action now to ensure that their billing operation will be in full compliance by next October and incur no disruption in cash flow or patient services. The first step is to contact your own PMS vendor and obtain very specific information. Three large anesthesia billing systems companies had registered their information on the Web site as of the time this column was written. If you use a vendor who has not yet given you satisfactory information regarding its HIPAA-readiness and who is not on the Web site, you might be able to use the fact that the Web site is providing other vendors with a competitive advantage to jog your own vendor into action.

Questions to Ask Your Vendor
For those anesthesia groups that are unsure of their PMS vendor’s HIPAA status or of what to ask the vendor, the Medical Group Management Association (MGMA) has developed the following list of questions for you to consider:

• Will the version of your software product that we currently use be able to send to all payers a claim/encounter form in the HIPAA standard X12 837 content and data format?

• Have your transactions been tested and certified by a third party as offering “HIPAA-ready” software?

• When will you be ready to upgrade my system? (Ask for a specific date.)

• Will the HIPAA modifications require a new version of my PMS software?

• Will I require any new hardware to support these modifications?

• When will you be sending me a schedule of testing that includes: - Internal testing - Testing with a clearinghouse (if applicable) - Testing with Medicare - Testing with commercial payers - Testing with one of the certifying organizations?

• Will my modified system accept the National Provider Identifier (NPI) number (expected to be a 10-digit numeric number)?

• Do you offer a product or service that will assist me in completing my “gap analysis?” (Moving your practice from the paper 1500 form to the 837 electronic will probably require additional data elements.)

• Will you be providing training for this modification?

• What are the expected costs?

You should request all answers in writing. If your vendor does not offer an appropriate HIPAA solution, identify alternative products as quickly as possible in order to meet the deadline of October 16, 2003.

MGMA also recommends developing a contingency plan that includes setting aside cash reserves, instituting a line of credit at a local bank and establishing a relationship with a HIPAA-compliant clearinghouse permitting you to send paper or noncompliant electronic claims (at least for the short term), thus ensuring continual cash flow.

Note: Jim Johnson of PPM Information Solutions will be speaking on working with your vendor at the If you have not registered yet, there is still time to do so at <www.asahq.org/Washington/pmconf203.htm>.

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Pain Medicine

Billing for Daily Management of an Epidural

The 2003 Current Procedural Terminology, Fourth Edition (CPT-4™) will complicate billing for postoperative care of an indwelling epidural catheter. The CPT Editorial Panel has added a usage instruction to code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration) that would allow anesthesiologists to bill 01996 only for patients in whom the catheter was “placed primarily for anesthesia administration but retained for postoperative pain management.” Corresponding usage instructions direct physicians to report the daily management of catheters placed primarily for postoperative pain management (codes 62318, both thoracic epidural and 62319, lumbar sacral) with evaluation and management (E&M) codes.

The ASA RVG does not contain these usage instructions or match the new CPT descriptor. As ASA told the CPT Editorial Panel in our November 12 letter requesting reconsideration of this change <www.ASAhq.org/Washington/pmCPTItrepiduralfollow-upcodes.pdf>, “Physicians and coders are not accustomed to choosing between codes according to the therapeutic purpose of the primary procedure. The management of an epidural catheter in either the cervical (62318) or lumbar (62319) area is the same service regardless of whether it was placed primarily as the route of administration of the anesthetic and retained in place for postoperative pain management or whether an inhalation anesthetic was administered and a catheter inserted into the epidural space solely to provide postoperative analgesia.”

The 2003 CPT-4 book will contain this confusing differentiation. If we succeed in the quest for its elimination, our results will not appear until publication of the 2004 book. We are therefore advising anesthesiologists that the usage instructions may result in a conflict with existing private payer screens that preclude payment to anesthesiologists for E&M services provided in the postoperative period. If this problem arises, payers will have the choice of reverting to 01996 in all scenarios (at least until compliance with the HIPAA transaction and code sets rules becomes mandatory on October 16, 2003) or revising their claims edits to permit processing of E&M codes billed together with an anesthesia service (0XXXX codes). Anesthesia practices may wish to negotiate such a revision with their contracted carriers.

New Medicare Specialty Designation Codes for Interventional Pain Medicine – and for Anesthesiologist Assistants (AAs)
ASA successfully urged CMS in 2001 to issue a new specialty designation code for pain management. Last year, we supported the creation of another new code for the subspecialty of interventional pain medicine. Effective April 1, 2003, anesthesiologists or pain physicians will have a choice of three specialty codes — anesthesiology, 05; pain management, 72; and interventional pain medicine, 09 — and may list up to two codes on their Medicare enrollment forms.

The specialty designation may be useful for Medicare carriers to develop practice profiles for pain physicians. There may be less chance of an audit for a high number of E&M claims if one is a pain specialist than if one is an anesthesiologist. Beyond that, the effect of adding or substituting a “pain management” or “interventional pain medicine” code is not clear. Medicare policy does not suggest any impact on practice income.

CMS also has created a new code for anesthesiologist assistants (AAs). AAs will now be able to designate themselves as such using code 32. Until April 1, they will continue to be included in the same code (43) as nurse anesthetists. Here again, the more precise specialty designation will permit the development of focused practice profiles.

To select specialty codes, physicians and AAs must submit CMS Form 851 to their Medicare carriers. The form is available at <www.hhs.cms.gov>. CMS’ notice to the carriers, Transmittal 1779, also may be downloaded.

Note: The HIPAA.org/PMS Directory Web site is discussed in the December 23-30 issue of American Medical News.

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Pay Attention to Pain Medicine When Negotiating Hospital Contracts Judith Jurin Semo, Esq., ASA Legal Counsel Squire, Sanders & Dempsey L.L.P. Washington, D.C. Should exclusive contracts include chronic pain services or not? The PRO/CON discussion on this topic in the October 2002 issue of the ASA NEWSLETTER reflects arguments on both sides of the debate. Perhaps the most important, but unstated, take-home message is the need for an anesthesiology practice to decide whether it is in its interest for an exclusive contract to include, or not to include, pain medicine. If a contract is ambiguous, the practice may find that its wishes, either to provide pain medicine services or not to provide them, are thwarted. Practices that have hired fellowship-trained pain medicine practitioners and expect to provide pain services are in a wholly different position from practices that affirmatively have decided to provide only surgical anesthesiology and acute pain services. In summary, anesthesiologists should consider what position works best for them and to make that intention clear in their service agreements with hospitals and ambulatory surgical centers.