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the past few years, as more anesthesiologists have
chosen to make pain medicine either a majority emphasis
or even the sole focus of their practice, ASA leadership
also has made the support of that discipline a priority.
Despite unprecedented pressures placed upon ASA
in regard to economic and political issues surrounding
operating room practice, ASA officers and staff
of the Washington Office have focused on the needs
of pain medicine practitioners. This can be seen
in the Society’s relationships with public
and private payers, governmental regulators, the
American Medical Association and various other pain
specialty societies.
ASA’s attention to pain medicine also is evidenced
in the development of several new Current Procedural
Terminology™ code initiatives, in support
of the educational efforts of the American Society
of Regional Anesthesia and Pain Medicine (ASRA-PM)
and in an unprecedented amount of time dedicated
to pain medicine workshops, lectures and panels
at the Annual Meeting. In addition I can testify
that there are some very large brains among our
colleagues on the Committee on Pain Medicine and
the Committee on Economics who are working to protect
the interests of anesthesiologists who provide pain
medicine services. I see smart people!
Some of these efforts go unseen by the membership
at large, but the past few months of work by the
leadership and staff have resulted in some excellent
gains for pain practices. In this article, I discuss
some of those efforts and also some of the Internet
resources available to the pain medicine practitioner.
Both ASA and your computer can be significant aids
as you manage your practice. I also will mention
a hot topic concerning the use of an evaluation
and management code on the same day a procedure
is done.
ASA and Carrier Reimbursement and Documentation
Policies
Working with the physician members of the ASA committees
on Pain Medicine and Economics, the ASA staff has
quietly effected improvements in restrictive reimbursement
policies by payers for both chronic and acute pain,
even before they were published. For instance, hard
work in such situations has now led to edits by
McKesson and Aetna that allow unbundling of fluoroscopy
charges (76005) from spinal injection codes. Practitioners
who find payer or Centers for Medicare & Medicaid
Services (CMS) carrier policies of concern or who
encounter reimbursement decisions that seem inappropriate
or unfair have found success in altering them either
by contacting a member of the Committee on Pain
Medicine <www.ASAhq.org/aboutASA/ASACommitteeListing.htm>
or by calling the able staff of the ASA Washington
Office at (202) 289-2222.
What the Internet Can Tell You About Reimbursement
and Documentation
Members are reminded to keep track of Medicare carrier
policies by monitoring where such policies are posted
for evaluation prior to commitment as well as after
adoption <www.cms.gov/mcd/search.asp>.
These policies, once referred to as Local Medical
Review Policies, or LMRPs, are now known as Local
Coverage Determinations, or LCDs, and are posted
before they are adopted, allowing comment
by concerned practitioners. Once you find your own
state’s Web page, set it as one of your browser’s
“favorites.” It is a good idea to habitually
set aside a few minutes once each month (e.g., the
first Tuesday) to make sure you do not miss any
potential changes in policy. The value of such vigilance
by individual practitioners cannot be overemphasized.
Carriers are responsive to pain practitioners’
concerns, particularly if they work through their
Carrier Advisory Committee (CAC). This strategy
beats the temptation we may all incur from time
to time to hammer directly on the often overworked,
overharried and underinformed Carrier Medical Director,
which sometimes accomplishes less-than-positive
results.
Such a system is not in place for all private payers,
although they do often post similar policies on
their company Web sites.
Another important resource is the evaluation and
management documentation instructions available
at <www.cms.hhs.gov/medlearn/emdoc.asp>,
which should be another addition to your Web browser’s
list of bookmarks. A further government Web site
with which you or your billing coders need to be
familiar is <www.cms.hhs.gov/physicians/cciedits/default.asp>.
This site lists all the edits associated with the
National Correct Coding Initiative (NCCI). CMS subscribes
to the NCCI, and so this site tells the viewer which
codes are not to be used with which other codes
and which codes are considered “bundled”
with others. It is updated quarterly, and its information
needs to be a regular part of your coders’
lexicon. You might also use it yourself when you
are analyzing your denial reports and see that you
are consistently being denied reimbursement for
a certain procedure code.
Again, repeated use of these resources will help
you to understand what your carriers and payers
are using to determine your reimbursement. If what
they are doing does not appear to be correct, try
contacting your CAC or call the ASA Washington Office.
There also are a wide variety of quality conferences
provided around the country to help physicians with
the management of their practices. One of the best,
if not the best, is put on by ASA every
February — next year, the annual ASA Conference
on Practice Management will take place in San Francisco,
California, on February 4-6, 2005. I highly recommend
it. (See
page 25 of this NEWSLETTER for details.)
ASA and Future Challenges for the Pain Medicine
Practitioners
The pain medicine practitioner faces increasing
challenges to his or her efforts to practice high-quality,
evidence-based medicine. A dearth of peer-reviewed
literature that portrays the efficacy of many of
the procedures that anesthesiologists provide puts
us at a disadvantage in trying to convince payers
that coverage of our work is warranted.
The good news is that ASA’s support means
that the largest advocacy group concerned with pain
medicine is at our disposal in presenting our case
to payers.
More good news is that, to further leverage its
impact, ASA has now joined the Pain Care Coalition,
a large and effective lobbying group.
All this help is great news for pain medicine physicians,
but it cannot be emphasized enough that no matter
how hard ASA works for you, you are your own best
help. As an increasing number of practitioners crowd
around a resource pie that seems ever smaller, pain
medicine practitioners must aggressively monitor
payer policies and their own individual treatment
outcomes so that the therapies they believe in remain
available to their patients. In that effort, however,
it is reassuring that ASA leadership believes so
strongly in the value of anesthesiologists as pain
medicine specialists. ASA continues to provide a
number of informed and dedicated pain physician
experts who work hard to aid the excellent ASA staff
in lobbying both governmental and payer policy makers
to further aid pain medicine practitioners in the
management of their practices.
A Quick Aside
About Evaluation and Management Coding:
With regard to evaluation and management
(E&M) codes, a frequently asked question
concerns the use of an E&M code for
evaluations provided on the same day as
a procedure. What follows is only my opinion
(not ASA’s):
Medicare allows the use of the –25
modifier for those same-day evaluations.
However, routine use of this
technique every time a procedure
is performed is not appropriate and is
a possible audit-trigger. Its use should
be reserved for those situations in which
the E&M event was more than simply
a confirmatory interaction prior to an
already planned procedure. A good rule
to follow is that E&M events should
be billed only when the original management
plan and decision are made, with all required
documentation provided.
Example A:
After an initial consultation, a patient
with L5 radicular pain is scheduled to
come in every week or two over a period
of three to six weeks for three lumbar
epidural steroid injections (ESIs). Each
time the patient comes in, the physician
bills for a follow-up E&M event and
an ESI, even though it was apparent that
the decision to provide all three injections
was made on the first visit. This is probably
an incorrect use of the E&M code.
Example B:
On the other hand, perhaps that patient
comes in for the second ESI and, after
evaluation, the physician decides not
to place another ESI because all the patient’s
complaints were now axial, and the radicular
component has resolved. Rather, after
evaluation of the interim history and
the current physical examination, the
physician offers to provide facet injections
that day. This is a new decision and is
due to the response of the patient to
the first injection as well as the current
physical findings. In this situation,
another E&M event has occurred and
could be charged for if appropriately
documented. |
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Douglas G. Merrill, M.D., is Staff Anesthesiologist
at Virginia Mason Medical Center, Seattle, Washington. |
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