December 2004
Volume 68 |
Number 12 |
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Medicare Releases 2005 Anesthesia
Conversion Factors
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
edicare payments to physicians will increase by approximately
1.5 percent in 2005. The national average anesthesia
conversion factor will increase by 26 cents to $17.76.
Anesthesiologists will receive slightly lesser or
greater percentage increases depending on where they
practice because of adjustments to the Medicare Fee
Schedule geographic practice cost indices. The calendar
year 2005 anesthesia conversion factors for the 92
Medicare payment localities can be accessed by clicking
here.
Anesthesia and Pain
Medicine Coding Changes for 2005
urrent Procedural Terminology (CPT®)
2005 contains one new anesthesia code. Two of the
pain codes reported by anesthesiologists have been
revised. The 2005 ASA Relative Value Guide (RVG) reflects
these changes. (Click
table to enlarge.)
The 2005 CPT book published by the American Medical
Association includes, in Appendix G, a “Summary
of CPT Codes Which Include Conscious Sedation.”
CPT codes for which conscious sedation is considered
an inherent part of the procedure (e.g., endoscopy)
are listed in Appendix G. These codes also are identified
by a symbol ( )
in the body of the book. Anesthesiologists and payers
should note that CPT distinguishes between conscious
sedation performed by the physician
doing the invasive procedure (e.g., the gastroenterologist)
and anesthesia provided
by a second clinician. The introductory text to the
appendix states, “The inclusion of a procedure
on this list does not prevent separate reporting of
an associated anesthesia procedures/service (CPT codes
00100-01999) when performed by a physician other than
the operating physician or a qualified professional
under the responsible supervision of a physician other
than the operating physician.” When an anesthesiologist
or “qualified anesthesia provider” performs
an anesthesia service for an endoscopy or other procedure
listed in the appendix, the anesthesia service is
payable as long as it is medically necessary. The
addition of Appendix G to CPT has not changed that
fact.
The ASA RVG and the ASA CROSSWALK™
and Reverse CROSSWALK™ have been
revised and updated for 2005. The CROSSWALK Editorial
Panel, a subgroup of ASA Committee on Economics members,
assigned anesthesia codes to the new 2005 CPT codes,
analyzed the revisions made to existing CPT codes
to determine whether they had any effect on the CROSSWALK
and conducted an in-depth review of the radiology
and colectomy sections. The 2005 RVG includes several
new coding comments or notes to clarify the use of
specific codes.
ASA published the print and electronic versions of
the RVG, CROSSWALK and Reverse CROSSWALK (CD only)
in early November 2004 in order to give practices
sufficient time to update their systems. Anesthesiology
practices should be prepared to implement the new
codes on January 1, 2005.
HIPAA
Is Still Out There
ilence can be significant. There has been a dearth
of questions related to the Health Insurance Portability
and Accountability Act (HIPAA) from ASA members in
the last several months. This suggests either of two
things: 1) that anesthesia practices have implemented
both the privacy and the transactions and code sets
rules without problems and are on track for the implementation
of the security rule or 2) that members with HIPAA
problems or questions are no longer contacting ASA.
We hope that the silence means only that you are solving
any problems easily at the local level.
Indeed there seem to have been fewer difficulties
with the implementation of the Privacy Rule than even
the federal government expected. The Government Accountability
Office (GAO) recently published a report titled “First-Year
Experiences Under the Federal Privacy Rule,”
the central message of which was the surprisingly
smooth course since the rule took effect in April
2003. The GAO’s primary source of information
was interviews with 23 organizations representing
patients, providers, public health and state government
officials and researchers, among others. The Department
of Health and Human Services (HHS), which fields direct
complaints and inquiries relating to the privacy regulations,
concurred.
Two specific issues were nevertheless the subject
of ongoing concern among health care facilities and
professionals as well as patient organizations. First,
misunderstandings of the duty to account for disclosures
of protected health information (PHI) have caused
many facilities to be overly cautious in their disclosures.
Public health agencies and disease registries have
been unable to obtain needed PHI. The GAO is recommending
that future privacy notices state that PHI will be
disclosed to public health authorities and that mandatory
disclosures to the authorities be exempted from accounting.
Second, the public does not understand the privacy
rule very well. Of the 2,741 complaints closed by
HHS in the first year of implementation, more than
35 percent alleged actions that the privacy rule does
not prohibit. Another 17 percent of complaints were
directed at someone other than a HIPAA “covered
entity” (e.g., hospitals, physician offices,
health plans). In only 9.4 percent had an actual violation
occurred. The GAO recommends a public information
campaign to improve awareness of patients’ privacy
rights.
To commit a criminal violation of the privacy rule,
venality and not just misunderstanding is required.
In the first criminal conviction under HIPAA, an employee
of the Seattle Cancer Care Alliance used a patient’s
name, date of birth and Social Security number to
obtain credit cards. He ran up a debt of more than
$9,000 in the patient’s name, pled guilty and
was sentenced in August 2004 to 10 to 16 months in
prison.
No information is available regarding any civil action
against the Seattle Cancer Care Alliance. Anesthesiology
practices — should they ever be so unlucky as
to hire an employee of this sort — might take
note of possible employer liability for third-party
losses caused by negligent hiring or supervision.
On the OIG’s Radar Screen for 2005
he vast majority of questions to ASA regarding compliance
with the Medicare payment rules have to do with
working with nurse anesthetists. There are other
billing practices that are of greater interest to
HHS’ Office of the Inspector General (OIG).
The OIG publishes its work plan for each calendar
year, identifying areas on which it will focus its
activities.
For 2005 the OIG will pay particular attention to
the following issues relevant to anesthesiology,
pain medicine and critical care in its investigations
of potential fraud, abuse or waste in physician
practices:
Billing service arrangements. The government
has long been troubled by billing service contracts
where the compensation is a percentage of billings
or collections. If the company’s compensation
is based in some way on the number and level of
services billed, there is an incentive to overbill.
The applicable section of the Medicare Claims
Processing Manual requires that “the agent’s
compensation [not be] related in any way to the
dollar amount billed or collected.” This
condition, however, does not apply “if the
agent merely prepares bills for the provider and
does not receive and negotiate the checks payable
to the provider/supplier.”
Coding of evaluation and management (E&M)
services. As in the past, the OIG remains
concerned that physicians are billing higher E&M
levels than justified.
Use of modifier -25. Modifier -25 denotes a significant,
separately identifiable E&M service that is
not included in a procedure or other service billed
on the same day. For example, a pain specialist
should not routinely bill a visit along with a
planned second epidural injection using the modifier.
Use of modifiers to override Correct Coding
Initiative (CCI) edits. The CCI lists thousands
of code pairs (“edits”) that cannot
ordinarily be reported together. Modifier -59
will override an “edit” that prevents
a physician from reporting separately a procedure
and one of its component services. Appending the
modifier to a claim for a lumbar epidural performed
at the same site, on the same day, as a lumbar
neurolytic might well seem abusive if not fraudulent
to the OIG’s investigators.
Lest physicians feel unduly targeted, it should
be noted that there are long lists of topics of
interest to the OIG on hospital, nursing home, home
health, durable medical equipment, laboratory and
other services in the 2005 work plan.
Source Material:
• Health Information: First-Year Experiences
Under the Federal Privacy Rule. GAO-04-965 (September
2004), <www.gao.gov/new.items/d04965.pdf>.
Accessed on November 1, 2004.
• Work Plan Fiscal Year 2005. Department of
Health and Human Services, Office of the Inspector
General (2004). <http://oig.hhs.gov/publications/docs/workplan/2005/2005%20Work%20Plan.pdf>.
Accessed on November 1, 2004.
• Reassignment of claims to billing agent:
Medicare Claims Processing Manual, Chapter 1, Section
30. <www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf>.
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