Red Light, Green Light: How to Record Accurate Start & Stop Times

As we’ve seen with the other major changes to the Relative Value Guide in 2019, the definition for accurate start and stop times has gotten more complex in order to allow for more flexibility. It seems counterintuitive that a more rigid definition can lead to more adjustability in practice, but it’s true. Surgery is a complicated process, and the recording of start and stop times of anesthesia is now more flexible to allow for the difficulty and variability of different surgical episodes. 

 

Prior to 2019, Anesthesia time had been defined by the RVG as beginning “when the anesthesia provider begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesia provider is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.” (x) This simple definition does not allow for times when unavoidable complications may disrupt the anesthesia care. How does the practitioner account for these interruptions? Do you estimate the numbers as though the care has happened for continuous periods? Or do you choose to underbill to stay on the right side of an audit? The new definition of recording start and stop times alleviates these concerns. 

 

Now, anesthesia time is still defined as “the period during which an anesthesia practitioner is present with the patient,” but may be counted in separate time blocks rather than continuously in order to provide a more accurate picture of the services provided to the patient. What does discontinuous anesthesia time look like? One example could be the time between the application of anesthesia and the start of a surgical procedure when a patient may be safely monitored by a non-anesthesia professional. Another example could be emergency transport of a patient who has already begun an initial contact with his anesthesia provider. Whatever the case, it is important to understand a few things about recording accurate start and stop times to remain compliant. 

 

How to Record

 

The main thing to note is that discontinuous time is NOT to be used or recorded while a surgery is underway. Otherwise, there is a relatively simple equation used to generate payments from CMS codes that include these flexible time units. Most of the factors in this equation are predetermined codes, but time units are generated by the anesthesia practitioner.

 

(Base Units x Time Units x Modifying Units) x Conversion Factor = 

Payments for Anesthesia Services 

 

The Base Units, Modifying Units, and Conversion Factors are all codes provided to you that describe the type of surgical procedure performed and the required application of anesthesia. Time units are measured in minutes, with 15- minute increments totaling one (1) unit. There are 4 units in an hour, and decimal points can represent partial units as accepted by most providers. For example, anesthesia services rendered for a 93 minute procedure would be 6.2 time units, with the last three minutes correlating to ⅕ or 0.2 of a time unit. Medicare accepts time units up to the tenth decimal, so accuracy is crucial. It is important to record your anesthesia time as diligently as possible, both to make sure you are accurately billing for services rendered, as well as protecting yourself from expensive audits. Vigilance in recording accurate start and stop times for anesthesia services can save you time and money in the long run. 

 

Contact us today if you still have questions. We want to help you succeed.

How are Anesthesia Fees Established?

Though it seems complicated at first, it’s not rocket surgery! De-mystifying the process by which charges are established for anesthesia services is a worthwhile exercise for everyone involved in the billing process. Surgery is not a yard sale where patients pay what they think is appropriate for services, or anesthesiologists bill what they think they’re worth! The CMS releases a finite set of rules regarding billing for procedures, and it’s important to learn to navigate the codes properly. You are responsible for your own paycheck! Submitting incorrect or inaccurate claims or unusable codes can delay or cancel payments. You and your anesthesia providers have already provided the services – make sure you are reimbursed properly! 

 

In general, here is the golden equation: 

(Base Units + Time Units + Modifying Units) x Conversion Factor = Anesthesia Fees 

 

Base Units

First, you select a base unit code for your claim. This code reflects the difficulty and skill involved in the procedure. Each CPT code, published yearly by the CMS, is assigned a base value by the ASA. Only one anesthesia code can be reported per claim, so check the list of CPT codes carefully. 

 

Time Units

Time Units are particularly important for rendered anesthesia services. In some cases, 1 minute represents a unit, ie. 60 units is equal to one hour. In other cases, the total minutes of the service rendered is divided by 15 (¼ of an hour) in order to create whole number time units. Be sure to check with your carrier as some utilize decimals in reimbursement, while some round up to whole numbers. 

 

Modifying Units

Not all carriers will accept modifying units, but the majority do. These include provisions for patients that have factors that can significantly affect the outcome of the procedure, ie. hypothermia, extreme age, obesity, and the position in which the procedure was performed. 

 

Conversion Factor

These are specific to each carrier and location where the procedure was performed. The list of conversion factors is published yearly by the CMS. 

 

Anesthesia Fees

This is the final fee paid for the anesthesia provided during a procedure, either by the patient or by the insurance carrier. Depending on your nature of arrangement with your hospital, you will either receive these fees directly as a contractor, or it will be paid out to your hospital or organization. 

 

Easy, right? No sliding scale, no abacus. By understanding these simple rules for calculating anesthesia fees, there should be no more mystery surrounding how you get paid. 

Still have questions? Contact us today!

Changes to the BCBS of Alabama Anesthesia Fee Schedule

BCBS of Alabama Mid-Year Update:

Are you aware of the changes to the BCBSAL Anesthesia Fee Schedule

Attention! If you are an anesthesia provider or coder and like increasing your bottom line, this is vital information for you. There are important Blue Cross Blue Shield anesthesia conversion factor increases that begin on July 1st, 2019 for Alabama. Since this is the first rate increase in four years, make sure your fee schedule payment amounts are correct by staying on top of these new changes!

 

BCBSAL Conversion Factors that will be changing on July 1st, 2019:

 

  • In total, the Conversion Factor will be increasing from $61-$63 per unit, or 3.2% overall.
    • Under Medical Direction, this will increase
      • MDA – $1.30 per unit
      • CRNA – $0.70 per unit
    • CRNA only practice will increase:
      • CRNA only – $1.40 per unit
    • Other Increases include
      • 01967 – Epidural for Labor & Delivery ($630.00)
      • 01968 – Anesthesia for C-Sections ($189.00)
    • Add on Codes increasing to $63:
      • 99100 – Extreme age, less than 1 or over 70
      • 99116 – Hypothermia
      • 99135 – Hypotension
      • 99140 – Emergency

If you work with these codes on a day to day basis, make sure you are paying attention to these important changes. Keeping up with the Blue Cross Blue Shield changes will make sure you are getting reimbursed the proper amount for your work!

Contact us if you have any questions or would like to know how this will impact your business.

The Field Avoidance Cheat Sheet for 2019

In an ideal world, all patients would be easy to sedate – flat on their backs, in a controlled environment, with no adverse reactions. Of course, this is never the case, so there are a thousand different ways in which anesthesia is administered and monitored. A tiny divergence in procedure can sometimes mean life and death for a patient. And when the procedure is over, a tiny divergence in coding, one wrong integer, can mean life and debt for a patient. Great anesthesia providers and their billing teams understand this, and stay on top of changes in the system

One of the trickiest qualifying circumstances to code can be field avoidance. Anesthesia providers haven’t had to pay close attention to this for a while, as the definition has, more or less, stayed the same. For 2019, however, there is a significant change. The definition of Field Avoidance has become more flexible as the requirements for documenting it have become more rigid. It is imperative coders and anesthesia providers communicate on these changes, as thorough notation of a patient’s position and reason for field avoidance are singularly important in the successful coding of this payout.

Let’s look at the language change from the Relative Value Guide:

  • 2018 RVG:  Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum Base Value of 5 regardless of any lesser base value assigned to such procedure.

This definition is fine, but does not account for cases where a patient is supine, but field avoidance must still be performed (ie., with morbidly obese patients).

  • 2019 RVG: Whenever access to the airway is limited (eg, field avoidance), the anesthesia work required may be substantially greater compared to the typical patient.  This anesthesia care has a minimum base unit value of 5 regardless of any lesser base unit valued assigned to such procedure.

The flexibility of this definition is meant to include the variation of the types of procedures that anesthesia providers must deal with daily. However, the one question the anesthesiologist must answer to the payor is: Is it justifiable to add the additional anesthesia reimbursement for this procedure?

Points to Remember

  • Field avoidance can be applied to surgeries performed in any position other than the supine or lithotomy positions.
    • The exceptions to this are procedures involving morbidly obese patients, or surgeries involving the head, neck, or shoulder.
    • Anesthesiologists are now no longer as strictly limited to anatomical position while still being covered by the payor.
  • Documentation of field avoidance must be accurate, detailed, and stress the difficulty of gaining access to the airway in the usual way.
    • Documentation must be marked on the patient’s anesthesia record. Anything recorded on internal billing documents is not considered part of the patient’s record and will not be covered as such.
  • The modifier -22 has to be added to the usual base value 5 code for field avoidance billing.
    • This modifier alerts the payor that the work required to provide the service (anesthesia) was substantially greater than the work typically required.
    • This absolutely applies to field avoidance, as it significantly increases patient risk during a procedure.
    • There are 83 codes with a base value of less than 5 units – that means there’s a good chance your anesthesia providers will qualify for this additional payment.
  • This only applies to payors that aren’t the CMS.
    • Medicaid unfortunately does not cover field avoidance.

Make sure you advise your anesthesia providers on these stricter documentation requirements, as crude stick drawings or unclear notations are no longer sufficient to cover this increased billing. Maximize your payouts by staying up to date with other 2019 medical billing changes.

It’s Time to Say “Thank You” to CRNAs!

Medical Business Management would like to join with the American Association of Nurse Anesthetists (AANA) in honoring Certified Registered Nurse Anesthetists during National CRNA week. The week of January 22-26 has been set aside to show appreciation for CRNAs and to raise awareness for the important work that they do.

CRNAs and Patients

CRNAs represent the personal side of anesthesiology. They are the ones that stay with the patient from start to finish during a medical procedure. They are likely to be the last face that you see when a procedure begins and the first face that you see as you regain consciousness. CRNAs are known for their personal touch. Many were drawn to this career because they enjoy the relationship with the patient and the role that they play in monitoring and maintaining each individuals wellbeing.

During a complicated medical procedure, there are a number of doctors and nurses involved in different aspects of your care. While many of these individuals are focused on specific tasks, the CRNA keeps a big picture perspective to ensure your overall well-being. This perspective can play a vital role in coordinating patient care and ensuring the best possible outcome. So as patients, we are happy to say, “Thank you CRNAs!”

Challenges Ahead for CRNAs

CRNAs in Georgia, Alabama, and Tennessee are facing new challenges. The migration from Cahaba GBA to Palmetto GBA has created a climate of uncertainty related to CRNAs and their status compared to anesthesiologists. Medical Business Management values our relationship with CRNAs nationwide, and we are committed to helping our clients navigate these uncertain times. Even if policies change, the expertise that we bring to practice management, coding, reimbursement, and billing will ensure that you are compensated fairly and in a timely manner.

Do you have questions about the work that we do CRNAs? Contact us today for more information.

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.

The Top 5 Things Anesthesia Providers Need to Know About Medicare Beneficiary Identifiers

Sample Medicare Card with Medicare Beneficiary Identifier

The Medicare Access and CHIP Reauthorization Act of 2015, commonly known as MACRA is bringing dramatic changes for Medicare beneficiaries and the providers that serve them. MACRA is bringing big changes for anesthesiologists and CRNA’s.

Could these changes result in rejected claims and unpaid charges? The answer is YES!

We are watching this transition closely and managing the transition process for our anesthesia providers. Since we have spent so much time working on MACRA, we thought that we would share the Top 5 Things that anesthesia providers need to know about how this will affect their practice.

The Top 5 Things Anesthesia Providers Need to Know About Medicare Beneficiary Identifiers

#1: MACRA requires removal Social Security Numbers (SSNs) from all Medicare cards by April 2019.

Health Insurance Claim Number (HICN) identifiers have come under increasing scrutiny because the prominent use of Social Security Numbers creates a significant risk for beneficiary identity theft. All beneficiaries will receive a new Medicare card by April of 2019.

#2: All beneficiaries will receive a new Medicare Beneficiary Identifier (MBI).

The new Medicare cards will replace the HICN with a Medicare Beneficiary Identifier (MBI) that doesn’t incorporate the SSN. MBI’s use the same number of digits as the HICN, and it will occupy the same fields. The MBI was designed to avoid commonly mistaken letters and numbers like “0” and “O”, and it is not based on the SSN in any way. This MBI is unique to each beneficiary.

#3: Transition period begins April 2018 through December 31, 2019.

Both numbers will work during that time. Starting on January 1, 2020, HICNs will no longer be exchanged with beneficiaries, providers, plans, and other 3rd parties. The HICN will only be used for appeal requests and related forms that were accepted using an HICN.

#4: This change will lead to complex system changes.

MACRA requires complex system changes affecting the federal government, state governments, beneficiaries, providers, and plans. These groups are spending countless millions of dollars implementing system changes that may directly affect your Medicare claim filing process.

#5: Failure to comply with MACRA will prevent you from getting paid!

Starting on January 1, 2020, your claims will not be paid unless they are filed appropriately using the new MBI. Any claim submitted with the HICN will not be processed, resulting in significant delays in getting paid.

Anesthesia Providers and MACRA

Medical Business Management works with CRNA’s and Anesthesiologists to ensure that their claims are submitted accurately and paid in a timely manner. We navigate the complicated transition process and manage your revenue cycle so that you can focus on what you do best: serve your patients.

If you would you like to find out more about MACRA; Contact us today about how these changes will impact your revenue cycle.

The ABCs of Calculating Anesthesia Time Units

calculating anesthesia time units

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result in delayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation.

Take a moment to look over this guide on the basics of calculating anesthesia time units so that your claims go through smoothly and accurately.

How to Determine and Report Anesthesia Time

Anesthesia time begins the moment the provider (the anesthetist) begins preparation for the patient, whether it’s in the operating room or in another area. An important thing to note is that any time spent looking over the patient’s medical records before surgery is not considered “anesthesia time” and is not billable. Instead, this is considered preoperative evaluation, and will be calculated in the base units.

The end of anesthesia time is marked by the moment the anesthetist is no longer personally attending the patient, and the patient has been moved into post-anesthetic care.

When it comes to the logistics of how one should report anesthesia time, the appropriate unit is 15-minute increments. Each 15-minute segment of anesthesia time is reported as one unit of time. So a 45-minute procedure would be considered three units of anesthesia time.

Accuracy is essential here, since Medicare pays to a tenth of a unit. Estimations of time are not appropriate. If the procedure lasts for 63 minutes, for example, then 4.2 time units would be reported – and that time should not be rounded up or down.

How to Calculate Reimbursement

There are specific formulas used to calculate reimbursement for a procedure based on the time units calculated for anesthesia time. The formula you use depends on who administered the anesthesia.

The formula for anesthesiologists or CRNAs would be:

(Base Factor + Total Time Units) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance

The formula for anesthesia performed under medical direction would be:

[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Again, accuracy is essential, as your process for calculating anesthesia time units can directly impact the overall charge, which then impacts your practice’s revenue.

What Else Should You Know About Calculating Anesthesia Time Units?

There are other considerations to be made here, too. For example, if there are interruptions in anesthesia care during a procedure, the exact times of the interruption should be recorded so that discontinuous time can be accounted for and any time that the anesthetist was not personally attending the patient will not be counted.

Additionally, most insurers will not allow for any more than one time unit for preparing patients for postoperative transfer to recovery. They also don’t allow you to bill for time that the patient is in a waiting room or another type of holding area. Patients also can’t be billed for any blood products or antibiotics that are given to them in a holding area, especially when those things could have been administered in a different part of the facility.

Questions about billing and coding? Get more information about how we can take that burden off your shoulders.

The ABCs of Physical Status Modifiers

physical status modifiers

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier.

The original version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the members of its organization. In Saklad’s opinion, the pre-operative classification of a patient’s physical status was a very useful statistical tool, and he was adamant that “no attempt should be made to prognosticate the effect of a surgical procedure upon a patient of a given Physical State.”

In 1962, when the ASA published a revised version of Saklad’s system, it failed to include examples. Numerous studies have proven that clinicians’ assignments of PS modifiers are quite subjective and not prone to consistency, resulting in multiple PS classes assigned to the same patient.

A Wide Range of Uses

Now, the ASA PS Classification System is used for many purposes beyond the characterization of a patient’s physical status as it relates to anesthesiology. Things like paying for anesthesia services, allocating risk, and predicting perioperative risk are all included in those purposes. For this reason, the ASA chose to use the following examples in its system so that classifications become more uniform.

physical status modifiers

The more consistency we can have in physical status modifiers, the better, because everything from work assignments to finances are affected by them.

Need help with your practice’s medical coding? Find out how we can help.

The ABCs of MAC Anesthesia

mac anesthesia

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery.

Read on to learn the basics of MAC anesthesia.

What Is MAC Anesthesia?

MAC stands for Monitored Anesthesia Care. Rather than just knocking you out, anesthetic medications are used to put you through a range of sedation levels. The level you reach depends on a variety of things — like your age, health, genetic factors, and how much of the drug you are given.

According to The American Society of Anesthesiologists (ASA), levels of sedation are divided into the following four categories. Each category’s official ASA definition is given next to it.

  •      Minimal Sedationa drug-induced state during which patients respond normally to verbal commands.
  •      Moderate Sedationa drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
  •      Deep Sedationa drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
  •      General Anesthesiaa drug-induced loss of consciousness during which patients are not arousable even by painful stimulation.

MAC does not appear in these official classifications, but it is most closely associated with moderate and deep sedation.

Why Are There Levels of Sedation?

Since most people prefer to be completely unaware during surgery, it begs the question: what’s the point of minimal and moderate sedation? There are two main reasons lighter sedation is sometimes used: recovery is much quicker, and there is less depression of the patient’s breathing and heart rate (as opposed to heavier drugs, which cause the patient to gradually lose the ability to breathe normally).

The most important thing about MAC anesthesia is to have a clear understanding of the level of sedation you are being offered before surgery. You should know exactly what to expect as far as your awareness and memory of the procedure (some anesthesia has the happy side effect of causing amnesia as far as the surgery goes).

Other problems can arise if the patient does not respond as expected to the sedation, and ends up either too lightly or too heavily sedated – but even with general anesthesia, there are about 2 in every 1,000 cases where patients are unintentionally aware.

MBM Supports Anesthesiology Practices

Our job is to handle your anesthesiology practice’s billing and coding so that you can focus on your patients, your staff, and your clinic. Contact us today for more information on how we can help!

How are Anesthesia Fees Established?

Though it seems complicated at first, it’s not rocket surgery! De-mystifying the process by which charges are established for anesthesia services is a worthwhile exercise for everyone involved in the billing process. Surgery is not a yard sale where patients pay what they think is appropriate for services, or anesthesiologists bill what they think they’re […]

The Field Avoidance Cheat Sheet for 2019

In an ideal world, all patients would be easy to sedate – flat on their backs, in a controlled environment, with no adverse reactions. Of course, this is never the case, so there are a thousand different ways in which anesthesia is administered and monitored. A tiny divergence in procedure can sometimes mean life and […]

It’s Time to Say “Thank You” to CRNAs!

Medical Business Management would like to join with the American Association of Nurse Anesthetists (AANA) in honoring Certified Registered Nurse Anesthetists during National CRNA week. The week of January 22-26 has been set aside to show appreciation for CRNAs and to raise awareness for the important work that they do. CRNAs and Patients CRNAs represent […]

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 […]

The Top 5 Things Anesthesia Providers Need to Know About Medicare Beneficiary Identifiers

The Medicare Access and CHIP Reauthorization Act of 2015, commonly known as MACRA is bringing dramatic changes for Medicare beneficiaries and the providers that serve them. MACRA is bringing big changes for anesthesiologists and CRNA’s. Could these changes result in rejected claims and unpaid charges? The answer is YES! We are watching this transition closely […]

The ABCs of Calculating Anesthesia Time Units

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result in delayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation. Take a moment to look over this guide on the basics of calculating anesthesia time units […]

The ABCs of Physical Status Modifiers

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier. The original version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the […]

The ABCs of MAC Anesthesia

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery. […]