ASA November 2003 Newsletter

November 2003 Volume 67	Number 11


	Mark Your Calendars: Conference on Practice Management, Fort Lauderdale, Florida, February 6-8, 2004 The 10th ASA Conference on Practice Management will be held in Fort Lauderdale, Florida, on the weekend of February 6-8, 2004. Innovations include discussion groups at which program speakers will answer further questions about their subjects in smaller and less formal settings. There will be presentations on hospital and ASC requests for proposals, measuring staff as well as clinical productivity, payment for monitored anesthesia and sedation services, operating room management and hospital stipend negotiations, among others. The number of registrants is limited; last year’s conference sold out, so watch your mail and register early.

Postoperative Epidural Management in 2004

Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)

The 2004 Current Procedural Terminology (CPT™) book resolves uncertainty that was created last year pertaining to the daily hospital management of an epidural.

The 2003 book introduced a parenthetical instruction that required anesthesiologists to report the daily hospital management of a continuous epidural placed for postoperative pain management with evaluation and management codes 99231-99233. Code 01996 was restricted for use only in those situations in which the epidural catheter primarily served to deliver an anesthetic for a surgical procedure and was retained for postoperative pain management.

Although it was incorrect to report code 01996 to Medicare for management of an epidural placed solely for postoperative pain management (and will remain improper until January 2004), many commercial payers instructed anesthesia practices to continue using 01996 as they had in the past.

ASA, represented by CPT Advisory Committee member H. Jay Przybylo, M.D., brought our concerns to the CPT editorial panel early in 2003. We pointed out that the selection of a particular code had never depended on the purpose of the procedure in the past or for other medical or surgical services. The editorial panel was receptive and agreed to revise the offending parenthetical after the descriptor for code 01996 as well as the parentheticals following codes 62318 and 62319. Effective January 1, 2004, it will no longer be necessary to report daily hospital management of a continuous epidural using the evaluation and management codes.

2004 CPT™ Coding for Continuous Epidural Injections

Effective January 1, 2004, the relevant codes and parentheticals will read as follows:

01996 – Daily hospital management of epidural or subarachnoid continuous drug administration (Report code 01996 for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter)

62318 – Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

62319 – lumbar, sacral (caudal)
(Report 01996 for daily hospital management of continuous epidural or subarachnoid drug administration performed in conjunction with codes 62318-62319

OIG Targets CPT Modifier Use, Evaluation and Management Services

The Office of the Inspector General (OIG) within the Department of Health and Human Services is responsible for Medicare fraud and abuse enforcement. Each fall, the OIG publishes its Work Plan for the following year, describing the various project areas perceived as critical to its mission. Audits, investigations, litigation and educational programs or materials will focus on these areas, which are selected because of their high overall cost and potential for fraud. Medicare payment for physicians’ services is just a small part of the Work Plan. The OIG also looks at hospital reimbursement, carrier and intermediary operations, information systems controls, nursing homes, ambulatory surgical center payment rates and many other areas.

Several items within the Work Plan section on “Medicare Physicians and Other Health Professionals” are worthy of anesthesiologists’ attention:

Use of Modifiers With National Correct Coding Initiative (CCI) Edits: The CCI lists thousands of pairs of codes that cannot be billed together. One important reason for an “edit,” or code pair, is that a procedure is an integral component of the “comprehensive” service. Oxygen monitoring, for example, is a component of an anesthesia service.

CPT Modifier 59 will override the edit for component codes of numerous specified services. Thus Modifier 59 will allow separate payment for transesophageal echocardiography (TEE) billed together with anesthesia for a valvuloplasty or for an epidural injection performed to provide postoperative pain relief. There are examples in all specialties. The OIG intends to study whether physicians are using modifiers to override the CCI edits correctly.

Note: ASA member Karl E. Becker, Jr., M.D., represents us on the American Medical Association Correct Coding Policy Committee. Whenever edits affecting anesthesiology or pain medicine are proposed, usually at the instigation of the Centers for Medicare & Medicaid Services (CMS) or carrier physicians, CCI contractors solicit our comments. We have persuaded CCI to make a number of changes, including notably the decision to continue allowing Modifier 59 to be used with intraoperative diagnostic TEE.

Evaluation and Management (Visit) Services; Use of Modifier 25: Because of the huge amount of spending on evaluation and management (E/M) services ($23 billion in 2001), CMS remains very interested in the extent of “upcoding,” or the use of a higher-level E/M code than warranted. The agency plans to assess the adequacy of carrier efforts and controls to identify physicians “with aberrant coding patterns.”

Anesthesiologists, especially those who concentrate on pain medicine, also should be aware that the OIG is watching the use of Modifier 25. This modifier denotes an E/M service that was provided on but is unrelated to a procedure billed on the same day. Nearly $2 billion of the $23 billion spent on E/M services was for visits billed with Modifier 25.

Consultations: It can be easy for physicians to confuse “consults” and “visits” in Medicare-speak. A “consultation,” for CPT coding purposes, only occurs when a patient is returned to the referring physician, who receives a report from the consultant. (For more information on the difference, see the “Practice Management” column in the February and November 1999 issues of the NEWSLETTER.) Since consultations yield higher payments than visits, CMS will continue to scrutinize them.

Place-of-Service Errors: Similarly Medicare pays a greater amount for professional services performed in a physician’s office than in a hospital outpatient department (OPD) or ambulatory surgical center (ASC). Since the physician taking care of patients in an OPD or ASC is not incurring practice expenses (Medicare reimburses these directly to the facility), the physician should code the place of service accurately.

Billing for Diagnostic Tests: In explaining its intention to assess the medical necessity of diagnostic tests, the OIG uses the example of nerve conduction studies. Pain specialists should take care to document the medical necessity for such studies and also for EMGs. Furthermore physicians should be familiar with their local Medicare carriers’ medical review policies. These are available on the carriers’ Web sites and at <www.cms.hhs.gov/mcd/search.asp?>.

Source Material:

• OIG Work Plan for Fiscal Year 2004 <www.oig.hhs.gov/publications/docs/workplan/2004/Work%20Plan%202004.pdf>.

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