November 07, 2011
Changes for Anesthesia Claims Under 5010 Transaction Code Set
ASA has received a number of questions regarding changes in reporting anesthesia services after the implementation of the 5010 transaction code set standards. The transaction code sets are mandated under the administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA). The X12 Standards Organization develops the standards for the transaction code sets. Among many other functions, the transaction code sets determine how electronic claims are submitted to payers. Currently, version 4010 is in use. The latest version of these standards is referred to as the 5010 standards and all HIPAA covered entities will be required to transition to the 5010 by January 1, 2012. Several of the 5010 changes have raised concerns among members and are addressed here.
One major concern is significant confusion among both anesthesiologists and payers regarding the information necessary to report anesthesia services. The new standards appear to require anesthesiologists to provide the surgical code in addition to the anesthesia code on claims. A few payers have also indicated that they will require this because the 5010 standards require it. This is a misinterpretation of the standards.
ASA has confirmed with the X12 Committee that developed the 5010 standards that no such requirement exists. The new standards allow anesthesiologists to submit surgical codes if they want to do so, but does not require this. The standards do not allow payers to require anesthesiologist to submit those codes. The ASA is working with X12 and payers to clarify these new requirements and the limits to which payers can require additional information on claim forms.
Documentation from X12 indicates that the surgical code is only reported on a claim for anesthesia services when the anesthesiologist knows the surgical code and the surgical code is necessary for claim adjudication. Payers can create a requirement for the surgical codes through contracts. Physicians should review all contracts to confirm that they do not create requirements where none exist under the transaction code set standards.
Another concern involves payers that will require additional information when physicians submit claims with codes containing “not elsewhere classified (NEC)” or “not otherwise specified (NOS)” in their descriptors. This may make sense for surgical codes because the CPT code set includes thousands of specific codes to describe almost every surgical procedure. CPT includes the NEC/NOS codes for those few instances when a specific code does not exist.
Anesthesia codes are constructed differently. Many anesthetics are reported with anesthesia codes that include “not otherwise specified” in their descriptors to cover anesthesia for a range of surgical procedures. It is impractical for anesthesiologists to submit additional individual information each time they report an NOS anesthesia code. ASA will work with payers to clarify how NOS is used differently in the anesthesia codes than for surgical codes.
A much less significant change in the new standards is that anesthesiologists will no longer report anesthesia time in units, but instead will have to report time in minutes, just as they do now for Medicare claims. Payers can still pay based on time units by converting the number of anesthesia minutes to time units. This can be accomplished through contractual arrangements between payers and anesthesiologists. ASA has previously addressed this issue and that information can be found here.
As always, ASA is available to provide information to members regarding these matters.