The Committee on Economics plays an important role in ASA’s education and advocacy missions. The tasks of the committee include reviewing and disseminating information concerning the economics of the practice of anesthesiology, reviewing private and government payment plans in order to make recommendations to officers and the House of Delegates concerning its findings and assisting component societies on economic issues. Oversight of the committee is provided by the Section on Professional Practice Chair Eric W. Mason, M.D., and the Vice-President for Professional Affairs Alexander A. Hannenberg, M.D., the immediate past chair of the committee.

To carry out these tasks, the committee meets three times each year and communicates electronically on a daily basis. The committee is composed of six members appointed to three-year terms and approximately 15 adjunct members appointed to one-year terms. Members include representatives from private and academic practices, “team” practices and practices in which anesthesiologists personally provide care and representatives of the Resident Component. Staff support for the committee is provided primarily through the ASA Washington Office. Karin Bierstein, J.D, Assistant Director for Governmental Affairs (Regulatory), and Sharon Merrick, ASA’s coding and reimbursement analyst, are invaluable in facilitating and coordinating the activities of the committee.

One important function of the Committee on Economics is developing codes by which anesthesia services are reported. Anesthesia codes occupy the “zero” series (i.e., 0xxxx) in Current Procedural Terminology™ (CPT), a publication of the American Medical Association (AMA). There are approximately 270 anesthesia codes that are used to report anesthesia services for approximately 6,000 procedure codes. Very few of the anesthesia codes are specific to a single surgical procedure, and some “cross” to dozens, if not more, procedure codes. (There are procedural codes — those for invasive monitors, pain management, critical care evaluation and management — that also are used by anesthesiologists.)

Codes are developed in response to new technology, and in the case of the codes for anesthesia for obstetrics, for example, to allow for more accurate and appropriate reporting of anesthesia services. The CPT Editorial Panel oversees the code development process and is assisted by representatives from multiple specialty societies on the Advisory Committee. Currently ASA is represented on the Advisory Committee by H. Jay Przybylo, M.D. Also Stanley W. Stead, M.D., is a member of the CPT Editorial Panel.

Once a code has been approved by the CPT Editorial Panel, it must be given a value, a task performed by the AMA Relative Value Update Committee (RUC). ASA is represented at the RUC by Norman A. Cohen, M.D., and Brenda S. Lewis, D.O.; James D. Grant, M.D., serves as the RUC advisor from ASA. The RUC valuation process is more political than the CPT process in that code values translate into payment for services, and the payment can potentially have a “negative” impact on payment for all other services. A component of the value assigned to a code is that of practice expense; Neal H. Cohen, M.D., represents ASA on this issue.

The RUC code valuation process depends on surveys of physicians involved in performing those services, and there is a minimum threshold of responses necessary for the survey to be considered legitimate. The surveys are usually targeted to ASA members who are likely to provide the service in question and have an understanding of the “service” codes used for comparison. If a member receives a request to participate in a survey, it is of tremendous help to ASA if he or she completes the survey in a timely manner; this is an opportunity for ASA members to have direct input into the code valuation processes.

The Committee on Economics’ most visible work product is the ASA Relative Value Guide (RVG). This publication is updated annually and reflects the code development and revision processes and the associated valuation process. The RVG follows the CPT policy of not publishing a code until it has been valued by the RUC. Also found in the RVG are guidelines concerning the use of time in reporting services as well as statements concerning monitored anesthesia care (MAC), reporting of the insertion intravascular catheterization procedures and transesophageal echocardiography. These statements originated from the committee and were adopted by the ASA House of Delegates. The MAC statement in particular has undergone two revisions since its inception. An important change in the definition of MAC, approved by the 2003 House, reads: “…if the patient loses consciousness and the ability to respond purposefully, the anesthetic is a general anesthetic, irrespective of whether airway instrumentation is required.”

Another important ASA publication for which the committee is responsible is the CROSSWALK™, which links the appropriate anesthesia code (perhaps with an acceptable alternate) to each procedural code. This publication, also updated annually, is overseen by the editor, Dr. Stead, along with Jan Gillespie, M.D., Craig M. Johnson, M.D., Dr. Norman Cohen and Ms. Merrick from the Washington Office. It is recommended that the RVG be used along with the CROSSWALK when deciding on the anesthesia code that best describes the anesthesia service provided.

The 2005 RVG and CROSSWALK, in print or electronic format, will be available from ASA headquarters in Park Ridge, Illinois, in November 2004. This is especially important for members to know, because as of January 1, 2005, Health Insurance Portability and Accountability Act regulations require that only “current” codes will be accepted, and there will be no grace period for transition from “old” to “new” codes.

In order to understand and be responsive to the economic concerns of anesthesiology subspecialty areas, the committee has formal liaison relationships with recognized anesthesiology subspecialty societies, the academic anesthesiology community and the Anesthesia Administrators Assembly.

ASA, through its Washington Office, has input to the Centers for Medicare & Medicaid Services (CMS), and knowledgeable members of the committee often participate in these discussions. The committee helps to reality-test solutions to problems (notably the rules of medical direction) as these are being negotiated with CMS. On an ad hoc basis, the committee communicates with the private payer community on issues of interest to our specialty. As an example, at a recent meeting of the committee, the medical director of the Blue Cross/Blue Shield Association of America made a presentation. An anesthesiologist on the Aetna policy staff will attend the October committee meeting.

Committee members, both individually and collectively, along with Ms. Bierstein and Ms. Merrick, offer guidance to members, their offices and billing services on the appropriateness of coding and reporting services. Unless the issue directly relates to an official position of ASA, it is made clear that any opinion offered should not be considered official ASA policy. The opinions by no means always affirm the coding and billing practice in question. If a provided service does not appear to be medically necessary (e.g., MAC for all endoscopic and pain management procedures), the committee has not hesitated to take a stand to support payment policies that do not cover “universal MACs.” It must be remembered that although there may be a code describing a specific service, even if the service is “medically necessary,” payers may choose not to cover the service (i.e., insertion of central venous catheter and pulmonary artery catheter on same patient).

The Committee on Economics takes very seriously its responsibility to advocate for the economic interests of the ASA membership, and this advocacy extends to the patients to whom we provide care. Having a reasonable and rational methodology of reporting our services helps put a visible face on who we are and what we do, and that face is one in which we should all take pride.

James P. McMichael, M.D., is a partner at Capitol Anesthesiology Association, Austin, Texas.