After all, payers still spearhead practice revenue
By Jody Hinton and Ladonna Schaad
So much media attention these days is focused on “patients as the new payer.” Yet despite the undeniable rise in patient co-insurance and deductibles, the simple truth is that the vast majority of practice revenue still comes from “traditional” payers. That makes it as important as ever to know how to properly and effectively navigate anesthesia coding rules, regulations and payer policies – and not use them as excuses for sub-optimal collection results.
That has long been a challenge, of course, given the ever-changing and complex nature of anesthesia coding. Still, with a deep understanding of overarching coding compliance principles, as well as applicable payer-specific claims, edits, and policies, practices can consistently safeguard payer reimbursement. For example, here are ways to address three commonly misunderstood aspects of anesthesia coding:
1. Anesthesia “provision/supervision” modifiers (-AA, -QK, -QY, -QZ, -AD and -QX) explain the role of the anesthesiologist and CRNA. These modifiers are essential for clarifying whether an anesthesia procedure was personally performed, medically directed or medically supervised by an anesthesiologist. Knowing what constitutes medical direction is only part of the challenge. State regulations can create another layer of potential confusion. For example, in some states, Certified Registered Nurse Anesthetists (CRNAs) can work independent of a physician’s medical direction, while other states do not allow such practice.
To ensure compliance, practices should take two steps: 1) discuss what they want to achieve in the operating room (OR) from a strategic standpoint, then 2) make sure physicians understand the appropriate medical direction criteria and that it is clearly documented.For example: A practice in a state where CRNAs cannot work independently might decide it wants its anesthesiologists to provide medical direction of only one CRNA, coded with -QY. Another practice might encourage its anesthesiologists to provide medical direction of two to four concurrent anesthesia procedures, coded with modifier -QK.
To support medical direction, CMS 100-4, 12 § 50 (C) states physicians must document that they performed each of seven medical direction functions: performed the pre-anesthesia exam and evaluation; prescribed the anesthesia plan; personally took part in the most demanding procedures in the anesthesia plan, including induction and emergence where indicated; ensured any procedures in the anesthesia plan not performed personally were done by a qualified anesthetist; monitored the course of anesthesia administration frequently; was physically present and immediately available for the diagnosis and treatment of emergencies; and provided indicated post-anesthesia care.
It’s important to note that medical direction applies only if a physician oversees four or fewer procedures. Any more than that, and practices must use medical supervision (modifier -AD), as explained in an American Society of Anesthesiologists (ASA) Timely Topics article.
2. Distinct procedural modifiers (-59, -XE, -XP, -XS and -XU). Payers routinely bundle the payment for some services into the payment for other services. Medicare calls these “bundled” services (CMS 100-4, 12 20.3). However, sometimes two procedures normally bundled together really are “separate and distinct” from one another. That’s where modifiers -59, -XE, -XP, -XS and -XU come into play.
To use CPT modifier -59 appropriately, CMS MLN Matters® article number SE1418 states that physicians must document “… a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”
However, CMS MLN Matters® article number MM8863 also points out that CPT instructions say modifier -59 should not be used when a more descriptive modifier is available. Although CMS still accepts -59, four more specific “separate procedure” modifiers may be used instead of -59 on Medicare claims. They are: -XE (separate encounter); -XP (separate practitioner); -XS (separate structure); and -XU (unusual non-overlapping service). Some examples of proper use are:
- -XS when two pain injections are performed for two different levels of vertebrae.
- -XU when a pain block for post-op pain is performed in pre-op holding (because the pain block is not the usual component of the anesthesia service being performed the same day).Further examples can be found from Novitas Solutions.
3. Discontinuous or extended time. Time is a unique but critical aspect of anesthesia coding. As a result, lots of misinformation surrounds start/stop time and discontinuous time. Here is a little clarity:
- Anesthesia time can begin before you enter the OR. According to CMS 100-4, 12 50 (G), anesthesia time “… starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.”
- Discontinuous time is recognized by Medicare and other payers. Again according to CMS 100-4, 12 50 (G): “Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.” Think of it this way: The idea is to bill for the total concentration and skill of the anesthesiologist.
Patient co-insurance and deductibles may be on the rise, but payer reimbursement remains the main source of practice revenue. Remember that underlying all correct coding and billing is clear documentation. For every segment of time, payers should have no question about where the provider is, what they’re doing, and why they’re doing it. In addition, anesthesia practices can help prevent payer reimbursement problems by partnering with experts who truly understand the bigger industry picture: not only what’s happening from a coding perspective, but why and how to address it compliantly. That is how anesthesia practices can trust they will receive all the revenue to which they are legally entitled.
We know from audits and clients that have transitioned their business to abeo that our competition will hide behind the payers to explain their collection efforts. For more information on abeo‘s expertise in anesthesia billing and revenue cycle management, visit us at https://www.abeo.com/anesthesia_billing/.