2018 Centers for Medicare & Medicaid Services (CMS) Rule Changes

Is your Anesthesia practice aware of all of the code changes for 2018? Incorrect coding could lead to delays in payment, and in some cases, it could completely prevent you from being receiving payment. Even when accurately reported, this code change represents a 40% reduction in base units, and many anesthesia practices are not even aware.

Medical Business Management is here to help! In this post, we give you the bottom line, although this year’s rule changes are complex and compliance is proving to be a challenge for anesthesia practices across the country. Contact MBM today to find out more about how your practice can ensure compliance and prompt payment every time.

2018 CMS Rule Changes

The CPT Editorial Panel is deleting two codes for anesthesia services related to upper GI procedures. Your practice should discontinue using these codes immediately.

  • 00740
  • 00810

They are creating new codes for upper GI procedures, lower GI procedures, and combined upper and lower GI procedures that should be used for all services billed in the 2018 calendar year.

Upper GI Procedures

There are 2 new codes that cover anesthesia for upper gastrointestinal procedures.

  • CPT code 00731 – 5 base units: This code covers anesthesia for upper gastrointestinal endoscopic procedures and endoscope introduced proximal to the duodenum unless otherwise specified.
  • CPT code 00732 – 6 base units: This code covers anesthesia for upper gastrointestinal endoscopic procedures, endoscopy introduced proximal to the duodenum, and endoscopic retrograde and cholangiopancreatography (ERCP).

Lower GI Procedures

The CPT Editorial Panel created a separate set of codes for lower GI procedures.

  • CPT code 00811 – 4 base units: 00811 should be used for anesthesia for lower intestinal endoscopic procedures and endoscope introduced distal to the duodenum unless otherwise specified.
  • CPT code 00812 – 3 base units: This code covers anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy).

Upper and Lower GI Procedure Codes

Finally, there is one code for anesthesia for procedures on both the upper and the lower GI.

  • CPT code 00813 – 5 base units: 00813 covers anesthesia for combined upper and lower gastrointestinal endoscopic procedures and procedures where the endoscope introduced both proximal to and distal to the duodenum

Conclusion

The CPT changes for anesthesia procedures are affecting anesthesia practices nationwide. Some practices are already experiencing confusion and delays in payment.

Medical Business Management can help your anesthesia practice cut through the clutter to ensure prompt and accurate payment. Contact us today about how these changes will impact your anesthesia billings.

Palmetto GBA Selected as Medicare Administrator for Jurisdiction J

The federal Centers for Medicare & Medicaid Services (CMS) has selected Palmetto GBA as the Medicare Administrative Contractor for Jurisdiction J. This jurisdiction, covering Alabama, Georgia, and Tennessee represents 7% of the national Part A/Part B claim-volume workload.

This change is having a dramatic impact on anesthesia practices across this 3 state regions. These practices have worked with Cahaba GBA for years, and the migration process will take some time.

What Your Anesthesia Practice Needs to Know about Transitioning to Palmetto GBA

Medical Business Management has thoroughly analyzed this process, and here are the key things that your practice needs to know about the transition from Cahaba GBA to Palmetto GBA. We have worked with Palmetto GBA for years supporting clients in other regions, and we believe that this change will be beneficial for anesthesia practices and CRNAs in Alabama, Tennessee, and Georgia, but the transition will be challenging and there are a number of pitfalls to avoid.

Claims Processing

All internal processing for Medicare claims has changed. Pay close attention to revised procedures for Palmetto GBA.

Online Tools

Palmetto GBA has a number of online tools that were not available through Cahaba GBA. Medical Business Management has used these online tools and features have enabled Medical Business Management to better serve our clients with coding and claims processing.

Is Palmetto Anti-CRNA?

Some CRNAs are concerned because the Palmetto’s manager is an anesthesiologist. It is possible that CRNAs will get cut out of some things. The best thing that CRNAs can do to manage the transition is to ensure accurate coding and compliance. Contact MBM today to find out more about how these changes might affect CRNAs.

Faster Time Frames

Credentialing takes an average of 60 days, but Cahaba GBA has been taking 120 days. They had a lot of employee turnover and they are trying to catch up using temporary employees. This strategy has not been effective to this point, but anesthesiologists should see an immediate improvement with the transition to Palmetto GBA.

Resources for the 3 Month Transition Period

Part B transition started on December 1, 2017, and the process will be complete on December 26, 2018. Our goal is to manage the transition process for our clients so that they don’t have to re-credential. This is a critical time for anesthesia practices and CRNAs. Do you have questions about the transition process? Contact us today to find out what you need to do to ensure a smooth process.

What Are the 2017 Changes to Epidural Steroid Injection Coding?

epidural steroid injection coding

As of January 1, 2017, CPT codes 62310-62319 have been deleted. In their place, new codes have been added so that the use or non-use of imaging with epidural steroid injections is now reflected. If your anesthesiology practice hasn’t yet updated its systems, do so now, using the following new ESI codes.

Why Have These Changes Been Made?

The new codes exist to identify whether or not imaging guidance has been used for each type of injection and anatomic area. The change in coding is a result of a CMS (Centers for Medicare and Medicaid Services) screen that identified possibly misvalued services pertaining to the Medicare Physician Fee Schedule.

According to CMS, the injection procedures were often reported together with fluoroscopic guidance (code 77003). CMS requested that these codes be reviewed by CPT.

The American Academy of Pain Medicine, together with several other professional medical organizations, addressed the concerns brought to light by CMS by establishing a new coding scheme. These new codes went into effect January 1, 2017, at which time it became inappropriate to report codes 77003, 77012, 76942, or any other guidance codes in conjunction with epidural injections.

New ESI Codes

62320 – Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic, WITHOUT IMAGING GUIDANCE (previous code – 62310)

62321 – WITH IMAGING GUIDANCE (i.e., fluoroscopy or CT)

62322 – Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal), WITHOUT IMAGING GUIDANCE (previous code 62311)

62323 – WITH IMAGING GUIDANCE (i.e., fluoroscopy or CT)

62324 – Injection, including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic, WITHOUT IMAGING GUIDANCE (previous code 62318)

62325 – WITH IMAGING GUIDANCE (i.e., fluoroscopy or CT)

62326 – Injection, including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal), WITHOUT IMAGING GUIDANCE (previous code 62319)

62327 – WITH IMAGING GUIDANCE (i.e., fluoroscopy or CT)

Deleted ESI Codes

62310 – Injection, single, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

62311 – lumbar, sacral (caudal)

62318 – Injection, including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid, cervical or thoracic

62319 – lumbar, sacral (caudal)

Overwhelmed by Coding? We Can Help!

We know how stressful it can be to run a practice and keep up with the latest in coding. That’s why we dedicate ourselves to handling coding for medical practices, which allows them to focus on their patients, staff, and office. Interested in learning more? Take a look at our coding services today.

What Is the Federal False Claims Act?

federal false claims act

The Federal False Claims Act places civil liability on practices that knowingly submit, or cause the submission of, a fraudulent or false claim. What could happen if your practice were found guilty of such an action? Keep reading to find out.

Penalties Under the Federal False Claims Act

Obviously, penalties abound for filing false or fraudulent claims. Civil penalties may include fines that amount to three times the cost of damages incurred by the government, and more charges of up to $21,563 per false claim.

Criminal penalties may include fines, as well – but you could be talking imprisonment, too. In the worst-case scenario, you’d face both.

With consequences like these, it’s vital to make sure that no one in your practice is filing false or fraudulent claims. If they are, and you don’t know about it, the liability is astronomical.

Healthcare Fraud: Deceit on a Large Scale

The U.S. Department of Justice reports that of the $3.5 billion the Federal False Claims Act recovered in 2015, $1.9 billion – that’s more than half – came from the healthcare industry.

Since 2009, $16.5 billion in healthcare fraud has been recovered and returned to federal healthcare programs. In 2015 alone, hospital settlements and judgments amounted to nearly $330 million. Settlements of $250 million were paid by nearly 500 hospitals for the alleged implantation of cardiac devices into Medicare patients, going against CMS criteria and/or without involving a cardiologist in the process.

The Overpayments Rule

The Affordable Care Act (ACA) mandates the Overpayments Rule, which requires practices to report an overpayment from either the state or federal government within 60 days from the day the overpayment is discovered.

Physicians who do not abide by this rule could find themselves subject to the Federal False Claims Act and its accompanying penalties – and the “ostrich defense” doesn’t actually give them any protection. According to the Centers for Medicare and Medicaid Services (CMS), “If the requirement to report and return overpayments only applied to situations where providers or suppliers had actual knowledge of the existence of an overpayment, then these entities could easily avoid returning improperly received payments and the purpose of the section would be defeated.”

That means your practice has to do enough due diligence to know whether there has been an overpayment – or risk being subject to the Federal False Claims Act.

Outsource Your Medical Record-Keeping to Stay Diligent

If you want to make sure your practice’s claims are handled properly, the best course of action is to hire a third-party billing and revenue cycle service provider. Medical Business Management can maintain your revenue cycle, process your claims, and keep your A/R days low. Contact us for more information!

How Your Practice Can Deal with Upcoding and Downcoding

medical billing and coding

Part of running a successful medical practice is navigating the complicated world of medical coding and billing. Doing so means understanding obstacles – both foreseen and unforeseen – and overcoming them with proven solutions.  

Two problems with medical billing and coding that are commonplace, but not always understood, are upcoding and downcoding. Both involve how you code services rendered when you file a claim for payment, and both can have an impact on revenue.

Here, we’ll talk about upcoding and downcoding, and cover the risks of both – and how to deal with these circumstances.

What Is Upcoding?

As a piece of the claims-filing process, each service rendered is coded with current procedural terminology codes, or CPT codes. A CPT basically tells the payer what specific service was performed. During the course of treatment, each service is recorded on the patient’s chart, which is then used to document the services that require payment.

Upcoding is when the CPT code listed on the claim is for a service or procedure that is at a higher level than the one actually performed and listed on the patient chart. This can be deliberate – which is fraudulent and illegal – or by mistake, but either way, it needs to be corrected.

The main risk of upcoding is an audit that reveals your practice has received more money than it was supposed to according to the actual services performed. Earlier this year, the Government Accountability Office reported that the federal government was overbilled by $14.1 billion in 2013 to Medicare Advantage practices. Thus, the government has a vested interest in eliminating overbilling and upcoding.

What Is Downcoding?

Downcoding is the opposite of upcoding. If you perform a service but record the CPT for a lower-level service, that is downcoding.

Downcoding also leaves you vulnerable to an audit, which is never good. But, it can also cost a practice thousands of dollars a year in lost revenue because you’re not getting the higher rate of pay that you would if you had recorded the service properly.

According to the National Correct Coding Initiative (NCCI):

“Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code.”

This is an important issue for compliance and for your bottom line.

Avoiding These Medical Billing and Coding Mistakes

One way to avoid these costly and risky mistakes is to conduct internal audits on a regular basis. During the audit, you’re looking to reconcile the service rendered on the patient’s chart with the services coded on the payment claim. This is your chance to catch any discrepancies before the claim is submitted. How often these audits are needed varies from practice to practice. We would suggest having an internal audit at least once a quarter – and having them more frequently if time allows.

Another way is to contract with a medical billing company to handle your coding and billing for you. This eliminates the risk of your staff committing errors, puts coding in the hands of trained professionals, and saves money. Not only can you avoid losing thousands in revenue, you can also cut down on overhead.

Upcoding and downcoding can hurt a practice. Avoiding them should be a practice’s main priority when it comes to billing.

Palmetto GBA Selected as Medicare Administrator for Jurisdiction J

The federal Centers for Medicare & Medicaid Services (CMS) has selected Palmetto GBA as the Medicare Administrative Contractor for Jurisdiction J. This jurisdiction, covering Alabama, Georgia, and Tennessee represents 7% of the national Part A/Part B claim-volume workload. This change is having a dramatic impact on anesthesia practices across this 3 state regions. These practices […]

What Is the Federal False Claims Act?

The Federal False Claims Act places civil liability on practices that knowingly submit, or cause the submission of, a fraudulent or false claim. What could happen if your practice were found guilty of such an action? Keep reading to find out. Penalties Under the Federal False Claims Act Obviously, penalties abound for filing false or […]

How Your Practice Can Deal with Upcoding and Downcoding

Part of running a successful medical practice is navigating the complicated world of medical coding and billing. Doing so means understanding obstacles – both foreseen and unforeseen – and overcoming them with proven solutions.   Two problems with medical billing and coding that are commonplace, but not always understood, are upcoding and downcoding. Both involve […]