Anesthesia Billing and Practice Management | Anesthesia Resources » CMS

ACO Resources now available from CMS

Robert Cox — Fri, 11 Nov 2011 16:09:23 +0000

The Centers for Medicare & Medicaid Services’ Medicare Learning Network
is offering several resources for providers looking for information on accountable care organizations and the Medicare Shared Savings Program.

Several electronic fact sheets that address topics are now available, including how to participate in an ACO and improve quality of care and information on the advanced payment model for ACOs. New fact sheets are also available detailing final rule provisions for ACOs under the shared savings program and fact sheets provide information on the methodology for determining shared savings and losses under the program.

ACO Rules Revised to Entice Greater Participation

Robert Cox — Fri, 21 Oct 2011 19:39:12 +0000

The latest ACO rules revision; requires half the number of performance measurements, removes the electronic health records requirement and eliminates financial risks for some groups. CMS also relaxed the timetable for the launch of the ACOs with groups allowing them to apply throughout 2012. To entice providers, CMS said it will make $170 million available starting next year to physician-owned and rural providers to start ACOs (Gold and Galewitz, 10/20).

ASA Urges MedPAC to Reject SGR Draft Plans to Cut 18%

Robert Cox — Thu, 06 Oct 2011 20:23:18 +0000

On October 5 and 6, 2011, the Medicare Payment Advisory Commission (MedPAC), the commission tasked with advising Congress on Medicare payment issues, will meet to review a draft recommendation that would help cover the costs of SGR repeal by cutting payments to specialty physicians, such as anesthesiologists, by nearly 18 percent over three years.

In a letter written to MedPAC in response to the proposed plan, ASA President Mark A. Warner, M.D., expresses strong opposition to the commission’s draft recommendation. Dr. Warner writes, “While we support permanently fixing the SGR, we believe cutting payment for anesthesia by 5.9 percent each year over the next three years, followed by a freeze in payment would harm patient access to care and does not take into account that Medicare currently pays anesthesiologists only 33 percent of the average commercial insurance payment for the same service.”

The proposed 10 year plan would differentiate specialty physicians from primary care physicians in regards to Medicare payments. For specialty physicians, the draft recommendation would reduce payments 5.9 percent annually in years 2012, 2013 and 2014, followed by payment freezes for the final seven years. Payments for primary care specialties would be exempt from the payment reductions and would instead be frozen at current 2011 levels for the entirety of the 10-year period.

ASA will continue to update members on the latest MedPAC developments.

Click here to read the letter ASA sent to MedPAC.

Anesthesiologists as ACO Leaders

Robert Cox — Wed, 07 Sep 2011 16:44:15 +0000

As hospitals, Ambulatory Surgery Centers (ASCs), and physician providers formulate the transparent partnerships the new rules require to participate in an ACO, it is important to be reminded that anesthesiologists are integral providers to achieve the goals of this new ACO concept. Anesthesiologists have been critical players in the initial assessment and on-going management of patient’s care throughout the perioperative and obstetrical arenas. In addition, Anesthesiology has been a champion for patient safety and has contributed data to the Anesthesia Quality Institute (AQI), for years.

Recent professional editorials have talked about creating a “surgical home” or an Accountable Anesthesia Organization as concepts where anesthesiologists would lead a team dedicated to the goals of an ACO. A recent article published in the Journal of the American Medical Association addressed the potential mistakes in implementing ACOs, particularly in failing to recognize interdependencies (http://jama.ama-assn.org/content/306/7/758.full).

It will be interesting to see the CMS response to the final rules for ACOs when they are made available.

Medicare Requires Revalidation of Physician Provider Enrollment Data

Robert Cox — Tue, 16 Aug 2011 13:34:39 +0000

Medicare is requiring all physician providers who were enrolled prior to March 25, 2011 to revalidate their enrollment data. Between now and March 2013, Medicare fiscal intermediaries will be sending notices to these physician providers, requesting that they revalidate their provider enrollment information contained in the PECOS system. Upon receipt of the revalidation request, physician providers will have 60 days from the date of the letter to submit completed enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. Providers can now utilize the Internet-based PECOS (Provider Enrollment, Chain, and Ownership System at https://pecos.CMS.hhs.gov.) to revalidate their provider information.

Physician providers who fail to revalidate their data timely could suffer financial hardship due to the interuption in Medicare payments until the revalidations is completed.

2012 Medicare Payment Rate Changes for Physician Fee Schedule

Robert Cox — Thu, 14 Jul 2011 13:00:30 +0000

On July 1, CMS (Center for Medicare & Medicaid) issued a proposed rule that represents a 29.5% cut to Medicare physician payments unless Congress steps in to correct it.

See the CMS press release at http://go.cms.gov/kssRvx

Dr. Donald Berwick, head of CMS was quoted in the press release saying, “This payment cut would have serious consequences, and we cannot and will not allow it to happen,” said Dr. Donald M. Berwick, CMS administrator, in a statement. “We need a permanent SGR fix to solve this problem once and for all. That’s why the President’s budget and his fiscal framework call for averting these cuts and why we are determined to pass and implement a permanent and sustainable fix.” Physicians groups have clamored for the SGR (Sustainable Growth Rate) formula to be overhauled as part of the deficit reduction process, but that would also come with a $300BB price tag.

Some provisions of the proposed rule include:

Physician Quality Reporting System (PQRS) – adding 26 new measures
Value-based modifier-CY 2013 as the initial performance year
Meaningful use
Misvalued code Initiative
Payment for certain Part B drugs
2012 e-prescribing incentive
Multiple procedure payment reduction (MPPR)
Physician payment during 3-day payment window

Comments are due back to CMS before August 30th. The final rule is expected by November 1st.

5 Most Common 5010 Transaction Rejections

Robert Cox — Wed, 13 Jul 2011 14:12:29 +0000

After extensive testing of 5010 claims transactions with Medicare, Medicaid, Blue Cross Blue Shield and commercial payers, clearing houses have identified the 5 most common rejections that practices need to fix to insure that there claims will pass the new 5010 edits.

1. Billing Provider Address - Claims are rejecting because the field contains a PO Box or Lock Box address.

2. 9 Digit Zip Code - required for the billing provider. This can be obtained by going to the US postal services website.

3. Provider Accept Assignment Code - claims will be rejected that do not contain a value value for the payers that are live for 5010 transaction (if Live the assignment needs to be “A” for assigned).

4. Priority (Type) of Admission or Visit - payers who are live for 5010 transaction will need a value code for the admission or visit priority. Contact your billing software vendor or your clearing house to insure that you are providing this priority type in the electronic transaction file.

5. Drug Quantity - the CTP segment has been modified to require the drug quantity when a drug is billed. Contact your billing software vendor to insure that the drug quantity is being included in the electronic claims transactions.

Practices must adopt the latest version of the HIPAA electronic transaction standards, Version 5010, by Jan. 1, 2012. These electronic transaction standards include claims, insurance eligibility verification, remittance advice and others.

CMS announces implementation of new fraud-fighting technology

Robert Cox — Wed, 22 Jun 2011 21:25:10 +0000

Beginning July 1, the Centers for Medicare & Medicaid Services (CMS) will begin using new predictive modeling tools to root out fraudulent Medicare claims. CMS says its approach is based on using real-time data to identify fraud as credit card companies do. Last year’s Small Business Jobs Act of 2010 provided funding – $100 million – for CMS to implement this technology.

The agency contracted with Northrop Grumman to develop processes to review claims by beneficiary, provider, service origin or other patterns and identify potential problems. Claims that raise concerns will be flagged and assigned a “risk score,” which will determine the agency’s next steps before it pays the claim. While CMS originally planned to roll out the program gradually, it announced last week that it will go nationwide on July 1.

How do practices know that this new technology will not interfere with timely payment of legitimate claims, if CMS won’t disclosed any detailed information regarding how the technology will be used. CMS usually rolls new technolgy out to a pilot group first. Not this time, they are rolling this out nationwide. I see cash flow issues for those physician practices who treat large volumes of Medicare & Medicaid patients.

To date, the government has not provided adequate details on this program. Click Here for the official CMS press release.

How to Bill for Anesthesia for an Emergency of Short Duration

Robert Cox — Thu, 19 May 2011 16:00:29 +0000

I was recently asked, “If one of my partners is medically directing a Medicare patient in OR #1 and an emergency C section needs to be performed on another patient because of fetal distress, is medical direction broken if the anesthesiologist begins the emergency case in OR #2 and remains there for 31 minutes, until an on-call CRNA relieves the anesthesiologist?”

CMS muddied the waters by stating that the medically directing anesthesiologist may perform other duties concurrently (sometimes known as the “Six permissible sins” of medical direction). These duties include:

Addressing an emergency of short duration in the immediate area
Administering an epidural or caudal anesthetic to a patient in labor
Performing periodic, rather than continuous, monitoring of an obstetrical patient
Receiving patients entering the operating suite for the next surgery
Checking or discharging patients in the PACU
Coordinating scheduling matters

The emergency case is clearly an emergency (CPT code 99140) and I think we can assume that OR #2 is in the immediate area. So what constitutes “a short duration”? My recommendation is to look at the expected on-call response time as your relative duration. Most anesthesia groups that utilize from-home, on-call for CRNAs, expect them to arrive within 30 minutes of being contacted (group policy statement). In the about example of the anesthesiologist starting the emergency C section and remaining in OR #2 for 31 minutes, would qualify for all three criteria and the case should be billed as medically directed and not subject to decreased reimbursement for broken medical direction (or supervision). My qualified opinion.

Anesthesia groups should use all resources available to them when faced with a situation that they have not encountered before. A few suggested resources are:

check with their fiscal intermediaries for guidance
post your situation on a respectable listserv so that your colleagues can share experiences
contact a consultant that might have experience with this issue

HIPAA Version 5010 National Testing Day

Robert Cox — Fri, 13 May 2011 13:44:57 +0000

The Centers for Medicare & Medicaid Services (CMS), in conjunction with the Medicare Fee For Service Program, responded to MGMA’s request and announced a National 5010 Testing Day to be held Wednesday, June 15, 2011. Practices must adopt the latest version of the HIPAA electronic transaction standards, Version 5010, by Jan. 1, 2012. These electronic transaction standards include claims, insurance eligibility verification, remittance advice and others. Practices should be taking steps now to get ready, including conducting internal and external testing with practice management system software vendors, clearinghouses and health plans.

National 5010 Testing Day is an opportunity for trading partners to work together and test compliance efforts that are already underway with the added benefit of real-time help desk support, and direct and immediate access to Medicare Administrative Contractors (MAC). Your local MAC will provide more details concerning transactions to be tested soon. Several State Medicaid Agencies are expected to participate in the National 5010 testing day.

More information on HIPAA Version 5010 is available on the CMS http://www.cms.gov/and MGMA (http://www.mgma.com/) websites.