Navigating Three Key Compliance Issues for Anesthesiologists

anesthesia billing specialist

Running an anesthesia practice means complying with a labyrinth of rules and regulations. There are three related compliance issues that many anesthesiologists have a difficult time abiding by, and all of them have to do with payment.

These compliance issues are:

  • Professional courtesy fee waivers
  • Co-payment waivers
  • Discounts for cash payments

Many practices encounter these issues on a semi-regular to regular basis, but may run afoul of generally-accepted legal principles and practices without knowing it.

To clear up any confusion, and to ensure proper compliance, here are the general guidelines for handling each of these situations.

Professional Courtesy

Professional courtesy is broadly defined as waiving payment from other physicians and/or their family members and employees. The Department of Health and Human Services’ Office of the Inspector General (OIG) covers this and other compliance issues in its Compliance Program for Individual and Small Group Physician Practices. According to this document, there are two broad considerations for whether or not professional courtesy is in violation:

  • How the provider selects the recipients of the professional courtesy;
  • How the professional courtesy is offered to the recipients.

Recipients generally can’t be selected because the provider thinks they’ll be a good source of referrals. This could run afoul of an anti-kickback statute that prevents providers from giving something of value in order to get business involving federal health care programs.

(Note that this may not apply to non-federal programs. Providing courtesy for those who aren’t in a position to generate Medicare/Medicaid referrals is generally allowed, as rare as that situation may be.)

The practical way to comply is to pre-determine groups of people to whom you will offer professional courtesy. In other words, don’t limit courtesy to just those who could be good referral sources. Instead, offer courtesy to any physician and their families/employees, regardless of their ability to send over business. Avoid the impression of impropriety by being more permissive and less restrictive.

Co-Pay Waivers

Waiving the co-pay (also known as “insurance only”) is similar to professional courtesy in that both involve reducing or eliminating the cost of a service to the patient. However, one key difference is this: waiving co-pays is almost always illegal.

Why is this the case? OIG doesn’t want practices to get into the habit of attracting more Medicare patients by waiving co-pays because doing so encourages excessive use of Medicare services by the general population. Additionally, OIG views doing so as fraudulent against the Federal Government because it misrepresents the practice’s normal fee.

It’s not just the Federal Government that views co-pay waivers as fraud; many states have gotten in on the action, too. Additionally, most health plans frown upon or outright forbid co-pay waivers.

Note that waiving co-pays for fellow physicians and their families isn’t illegal in the eyes of OIG, but when it comes to Medicare patients, it is illegal. In general, it’s best to never waive co-pays to avoid any semblance of impropriety.

You can learn more about the differences between co-pays and courtesy here.

Cash Payment Discounts

Finally, practices sometimes offer discounts for cash payments to patients, mainly to avoid costs associated with getting payment from insurance companies (as well as the uncertainty that often comes with dealing with insurers).

It’s not illegal to bypass insurance. What is illegal, however, is offering discounts and then billing the insurer anyway. This usually happens unintentionally due to poor record-keeping and administrative oversight (although some providers undoubtedly attempt to break the law and commit fraud).

When offering discounts, it’s important to always check with the terms and negotiated rates of your health plan contracts. You don’t want to undercut your own rates, or be in violation of your contract. Plus, you want to make sure each instance of offering a discount is carefully tracked, so you don’t offer a discount for a cash payment to a patient and then turn around and bill the insurer. Protect yourself by putting a plan in writing and abiding by it rigorously.

Understanding these compliance issues from a broad perspective is relatively simple, but comprehending the fine details and legal implications is a bit more difficult. If you have further questions, contact an anesthesia billing specialist to learn more and stay in compliance.

Understanding – and Abiding By – Anesthesia Documentation Requirements


anesthesia documentation

Compliance, for an anesthesia practice, is quite different from other medical practices and specialties – and can even differ within the anesthesia field.

Because so much depends on proper compliance, practices need to understand what is required of them when it comes to complying with rigorous documentation requirements. However, many providers – even those with decades of experience – have trouble keeping up with the myriad documentation standards out there. This is mostly because documentation guidelines change regularly, so what was in effect five years ago – or even a year ago – may not be in place today.

Here, we’ll provide a general overview of anesthesia documentation requirements. Note that you can get a more thorough understanding of all requirements by contacting a billing and coding specialist that works with anesthesia practices.

Examining the Basic Requirements

National standards for documentation come from the National Committee for Quality Assurance (NCQA), which publishes the Guidelines for Medical Record Documentation. In the guidelines, there are 21 separate elements. Not all of these apply to anesthesia practices.

The ones that do apply specify that each page in a patient’s record must contain the patient’s ID number or name. Additionally, all medical record entries must have the author’s ID, which can come in the form of initials, an electronic ID, or a handwritten signature. Finally, the record must be legible to others who read it, beyond the writer.

There are other guidelines available, such as the ones from the American Association of Nurse Anesthetists (AANA). Perhaps the most commonly used guidelines, other than NCQA, come from the American Society of Anesthesiologists (ASA). They don’t publish documentation guidelines per se, but do have several general guidelines that can be found here.  

Documentation Standards for Anesthesia Care

When we get into more specific guidelines (using those published by ASA), we break down the standards into three areas: pre-anesthesia care, intra-operative care, and post-operative care.

Pre-Anesthesia Care

Before anesthesia is administered, CMS mandates that pre-anesthesia documentation be signed by a medical directing anesthesiologist. Additionally, there are a few things that need to happen with a patient that must be documented, including:

  • Discussing the patient’s medical history, including any prior experiences with anesthesia
  • Examining a patient’s physical health for risk management
  • Ordering any tests and consultations that are necessary prior to care
  • Ordering any medications for pre-operative care
  • Obtaining and documenting consent from the patient before care is administered

As mentioned, providers must be careful to record that all steps were taken prior to the delivery of care.

Intra-Operative Care

During the administration of care, there are two standards. The first standard, as dictated by ASA, is that qualified anesthesia personnel need to be present in the room while all general and regional anesthetic care is delivered (including monitored anesthesia care).

The second standard is that qualified personnel should, during the administration of care, constantly monitor a patient’s circulation, temperature, ventilation, and oxygenation.

As with anything, adherence to these standards should be documented.

Post-Operative Care

Finally, standards for post-operative care stipulate that patients should be admitted to a post-anesthesia care unit (PACU) or another equivalent area, unless ordered to do otherwise by the anesthesia provider. The provider is responsible for the patient until a PACU can take over.

How Auditors Review Documentation

Documentation becomes critically important whenever a practice faces an audit from an auditor.

Auditors check documents to determine, among other things, that the anesthesia provider continuously monitored the patient and that the anesthesia time was properly documented. For example, auditors want to see notation that the provider checked the patient’s vitals once every five minutes at the very least. Additionally, auditors will check your recorded anesthesia time against records from the PACU and operating room. They may not match exactly, but they need to be very similar.

Auditors also review records for use of anesthesia modifiers. Use of modifiers, and medical direction in general, is covered by the Medicare Claims Processing Manual from CMS, which defines medical direction as: performing a pre-care evaluation, prescribing an anesthesia plan, personally participating in the most difficult portions of care, making sure that all procedures not personally administered are done so by a qualified anesthetist, monitoring anesthesia administration at regular intervals, staying present and available, and providing post-anesthesia care.

There are allowed exceptions, which are covered in more detail in the manual.

Ensuring Compliance with Regular Record Review

Staying compliant means constantly reviewing records to ensure they are complete and accurate, as well as conforming to standards. Internal review processes are exceptionally useful, provided that the reviewer and the record creator are two different people.

Compliance is crucial. Regular reviews from internal and external sources are strongly recommended. Every practice needs a formal plan for compliance, with written processes and standards to make sure all claims abide by standards established by CMS and insurers, and to ensure documents are correct.

Consult with a billing specialist to learn more about guidelines and standards for claim documentation and how to fully comply with them.

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Why Anesthesia Practices Should Consider QCDRs

qcdrs

For anesthesia practices participating in the Physician Quality Reporting System (PQRS) from CMS, there are four ways to take part: claims, qualified registries, electronic health records (EHR), and a fourth option known as qualified clinical data registries (QCDRs).

Most providers utilize one of the first three methods to submit data to CMS. However, there is still a degree of uncertainty involved with these methods, and really any claim-based reporting method.

That is why anesthesia providers are beginning to move toward QCDRs as a way to fully participate in PQRS. Here, we’ll outline the general concept of QCDRs and how to take part in this system.

QCDRs Explained

CMS describes a QCDR as a “CMS-approved entity…that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients.” CMS further clarifies a “CMS-approved entity” as a registry, certification board, collaborative, or other entity.

QCDRs collect data on quality measures – like the ones stipulated by CMS in their latest update to PQRS – and submits this data on a provider’s behalf to CMS. Data collected during performance year 2016 will be submitted to CMS during the first quarter of 2017.

There are a few noticeable differences between using QCDRs and using other reporting methods. When using claims, for example, providers must report nine PQRS measures from three NQS (National Quality Strategy) domains. In addition, they must report a cross-cutting measure if applicable, on at least half (50%) of their Medicare fee-for-service patients.

With QCDRs, however, professionals must report the same nine measures including two outcome measures on at least half of all patients. These outcome measures focus on the outcome of health care, versus the process behind care. This is due to a shifting emphasis on quality of health care – rather than processes – from CMS.

As mentioned, one of the biggest differences between a QCDR and qualified registries is the fact that with QCDR, you have to report on half of all of your patients, even those with private insurance. Additionally, you don’t have to report a cross-cutting measure; the two outcome measures replace that particular component (and can be a part of your nine reporting measures).

Benefits of QCDRs over Other Reporting Methods

One benefit of reporting via QCDRs is flexibility. Those reporting via qualified registries can only choose from an approved list of PQRS measures. With QCDRs, however, a provider can choose from PQRS measures and non-PQRS measures – hence making it easier to fulfill all reporting requirements.

Another benefit is ease-of-use. QCDRs are becoming known for how easy they are to use relative to other methods. Practices are discovering that the reporting burden – 2.6 hours per week on quality reporting, on average, per physician, according to an MGMA survey – is lower with a QCDR than with the alternatives.

The state of health care is constantly changing and evolving. The evolution of reporting from the old way to the newer methods (focused on quality of care and patient satisfaction) necessitates change, and practices that get on board now, rather than later, will reap the benefits.  

To learn more about how QCDRs are tied into a practice’s anesthesia billing and coding, contact MBM.

 

Understand the Impact of Proposed MACRA Regulations on Anesthesiologists

anesthesiologists MACRA

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act, known as MACRA. Since then, regulators have been working on releasing guidelines and programs governing MACRA, and many of these impact anesthesiologists.

Parts of the proposed rule (it hasn’t gone into effect yet) were announced on April 27 and discussed on this blog previously, including MIPS (Merit-based Incentive Payment System), APM (Alternative Payment Model), and Criteria for Physician-Focused Payment models. These regulations are contained in the 962 pages that comprise the MACRA ruling and are currently in a public comment session that ends June 27.

The final rule will be published later in 2016, but it is prudent that anesthesiologists understand the impact MACRA could make on their practices, if everything currently being proposed is enacted by January 1, 2017.

Here, we’ll briefly cover two of the most important pathways for physician payment: MIPS and APM.

MIPS

MIPS is a variant of the standard fee-for-service model that most practices have used for decades. The goal of MIPS is to help calculate all adjustments for providers that are linked to value and quality. As of 2019, the max bonus is 4%; the max penalty is -4%. These will be assessed based on four categories of performance (consolidated from the labyrinth of criteria that existed prior to MIPS): quality, cost, advancing care information, and clinical practice improvement activities (CIPA).

Each of these, except for CIPA, replaces a current program. Quality replaces PQRS; Cost replaces the Value-based Modifier (VBM); and advancing care information replaces the EHR Incentive-Meaningful Use program.

In the first year, percentages of a practice’s MIPS score will be allocated as follows:

  • Quality: 50%
  • Cost: 10%
  • Advancing care information: 25%
  • CPIA: 15%

Those percentages will shift over time. Quality, for example, will be reduced to just 30% of the total score by 2022.

CMS estimates that negative payment adjustments under MIPS will approximate $833 million, while positive payment adjustments will total $1.3 billion. All anesthesia practices naturally want to be in the latter category.

APM

The other payment model is the Alternative Payment Model, or APM.

APM is actually a system of models, including Medicare Advanced APMs and Other Payer Advanced APMs. There are stringent requirements for participating in APM over MIPS, to the point where most anesthesiology practices will be under MIPs. But in the future, MIPS will eventually transition into APM, so it’s important to understand where the field is headed.

The goal of APM is to encourage a value-based payment system in which providers strive for efficient care of a high quality. Payment for participation under APM is a 5% lump sum payment of the aggregate payment amounts under Medicare Part B for the prior year; this is in effect from 2019 to 2024. Starting in 2026, payment rates will see a 0.75 percent bump.

What qualifies a provider for APM? They must have a significant portion of their practice’s payments coming from payment models that include, at a minimum, a risk of financial losses and use of EMRs as quality measures. There may be other qualifications as the role of an APM is solidified throughout 2016.

As mentioned, most providers will not qualify for APM; they will instead be placed under MIPS until MIPS is gradually phased out in favor of APM.

The best course of action today for anesthesiologists is to familiarize the practice with both models, MIPS and APM, and keep abreast of changes as MACRA becomes ratified later this year. Until then, they should focus on increasing quality scores as much as possible and streamlining practices so adoption of new quality measures is easier down the road.

3 Helpful Tips for Choosing Anesthesia Billing Companies

anesthesia billing companies

Choosing anesthesia billing companies to handle coding, billing, provider credentialing, and revenue cycle management for your practice is a wise choice because you can lower costs, increase efficiency, improve patient service, reduce claim denial rates, boost revenue, reduce overhead, and avoid penalties from not complying with regulations.

With all the different providers out there, selecting among the anesthesia billing and provider credentialing companies in the market can be difficult. You want a provider who can be relied upon to provide exemplary service so that you can focus on your practice.

What qualities should you look for in billing providers? What are the indicators for success for a new relationship with a third-party vendor?

Choose a Comprehensive Provider

There are many aspects to revenue cycle management for an anesthesia practice. From coding to billing, claims processing, patient communication, collections, and more, the number of moving parts in a practice’s system can be overwhelming – as can hiring a provider for each specific part.

Instead of outsourcing to a slew of vendors, it makes more sense to choose one provider who can offer a comprehensive solution incorporating all the necessary components of a revenue management system.  This creates greater synergy and efficiency, and also gives you just one point of contact instead of several.

Go with Specialty Services

When it comes to billing, you generally have two options: general contractors or specialized contractors.

For an anesthesia practice, it’s better to go with specialists who know the ins and outs of billing, coding, and filing for anesthesia providers. This is because there are many regulations and facets to anesthesia billing and coding that other practice areas do not have to consider – and having a generalist do the work for you could mean you’ll miss out on valuable experience in your chosen field.

For these reasons, it’s advised to find a provider who specializes in billing and coding for anesthesia practices, and has a body of work and successful track record for those practices — not just any medical practice. Your success rate will be much higher with a specialist.

Choose Based on Reputation

The provider you choose ultimately should have a reputation for integrity, diligence, and results. You can determine if this is the case by either checking out reviews of the provider online – such as through business directories, Facebook, Google, etc. – or by asking for references from clients.

Either option will give you a good idea of what you can expect during a working relationship with your third-party provider. Anesthesia billing companies should be willing to share with you the results of their previous relationships, and should have no problem allowing you access to references.

Reputation is important. The number of providers out there necessitates narrowing down the list based on reputation and only finding partners who have reputations for excellence.

Following these tips can help your practice find the right anesthesia billing companies to cut costs, boost revenue, reduce claim denial rates, and improve the running of your practice.

Calculating Time Units for Anesthesia Billing and Coding

anesthesia billing and coding

Calculating time units for anesthesia billing and coding is extremely important. Failure to do so accurately can result in denied or delayed claims, which negatively impacts revenue. It can also result in audits which can further hurt a practice’s revenue and reputation.

Here is a guide to correctly calculating time units for all claims and reports, to ensure your claims go smoothly and are as accurate as possible.

Determining and Reporting Anesthesia Time

According to Current Procedural Terminology (CPT) guidelines, anesthesia time begins when the provider – the anesthetist – starts preparation for the patient, either in the operating room or another similar area. Note that time spent reviewing medical records before the surgery is not billable. This is a part of preoperative valuation, which is calculated in the base units.

Anesthesia time ends whenever the provider is no longer personally attending the patient, and when the patient is safely placed into post-anesthetic supervision.

The proper way to report anesthesia time is to record it in minutes. One unit of time is recorded for each 15-minute increment of anesthesia time. For example, a 45-minute procedure, from start to finish, would incur three units of anesthesia time. Being exact is required, since Medicare pays to one-tenth of a unit. Do not estimate the time or round up or down inappropriately. For example, for a 63-minute procedure, one would receive 4.2 time units (four time units x 15 minutes plus 1/5th of a time unit, or 0.2).

The Formula for Reimbursement

Using time units calculated from anesthesia time, one can calculate reimbursement for a procedure using a certain formula, depending on who performs the anesthesia.

For anesthesiologists or CRNAs:

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

For anesthesia performed under medical direction:

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

One can see how accurate time unit calculation can play into and directly affect the total charge, which in turn impacts revenue.

Considerations for Billing and Reporting Time

Discontinuous Time

There may be interruptions in care during a procedure, marked by when the provider is no longer personally attending the patient. By recording the exact times care was interrupted, one can accurately report discontinuous time.

For example, if the anesthesiologist begins care at 8:00, but has care interrupted at 8:24 and resumes care at 8:36 before ending care at 9:04, there would be 52 minutes of anesthesia time. This would translate to 3.47 time units.

What Not to Bill

Generally speaking, most insurers allow for no more than one time unit to prepare patients for postoperative transfer to recovery. Insurers also do not allow billing for anesthesia time while the patient is in a waiting room or holding area. Also, when in the holding area, patients usually cannot be billed for antibiotics or any blood products that are administered. This is particularly the case when those services could be performed in another part of the facility.

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Understanding PQRS and Anesthesia Billing

pqrs anesthesia

The Physician Quality Reporting System (PQRS) is a quality reporting system created by the Centers for Medicare & Medicaid Services designed to properly assess the quality of care that is provided to patients.

Providers can use PQRS to quantify how often they are meeting a certain quality metric, and can modify their care based on feedback provided to them by CMS (particularly in relation to their peers).

Of course, the main reason many providers want to understand and embrace PQRS is due to fee adjustments that result from not adequately participating. Failure to participate will result in a 2.0% adjustment in their fee schedule amounts in 2018 for the 2016 reporting period. That adjustment is scheduled to increase in coming years.

For anesthesia providers, there is much to understand about PQRS and anesthesia billing. Here is a breakdown of what providers need to know to familiarize themselves with the program.

Quality Measures in PQRS

The particular measures of quality contained in PQRS and anesthesia billing change from year to year. They also vary by specialty. Those for anesthesia are different from those for, say, physical therapy.  The general areas on which the system focuses typically include:

  • Care coordination
  • Patient safety and engagement
  • Clinical processes and effectiveness
  • Population/public health

Providers can select the appropriate measures to use in their reports. One rule is the 2016 cross-cutting measures requirement. This stipulates that a provider must use a cross-cutting measure – one that is “broadly applicable across multiple providers and specialties” – if they have had at least one Medicare patient with a face-to-face encounter. For anesthesia professionals, most, if not all, visits will involve a face-to-face encounter.

More information on quality measures for PQRS can be found on the CMS website.

Understanding the Value-Based Modifier

Under the Affordable Care Act, a value-based modifier is now required by CMS (as of 2015). This is an effort to move toward pay-for-performance and away from fee-for-service.

As of January 1, 2016, the value-based modifier will be applied to all physician groups under a single Taxpayer Identification Number (TIN) with 10 or more eligible professionals. In 2016, however, the modifier will not be applied if a group had at least one eligible professional participate in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization Model, or the Comprehensive Primary Care Initiative.

Anesthesia providers need to prepare for 2017, when the modifier will be applied to all TIN groups that include solo practitioners or groups with two or more eligible professionals.

Value-based modifiers are selected on a tiered system known as “quality-tiering.” Quality-tiering will become a very significant factor in determining payment, and will deliver either upward, downward, or neutral fee adjustments based on your particular tier. The tiers will be evaluated based on how well a provider group performs compared to the national mean – better, the same, or worse.

Quality tiering can dramatically influence payment adjustments. For example, the highest adjustment tier in coming years will be a negative 4-percent adjustment for those found to be in the bottom third tier among their peers. The system is designed to provide an incentive for provider groups to be at least in the top 50% of all peer providers in order to avoid negative adjustments.

Categories for the Value Modifier

In 2016, as in 2015, all provider TINs will be grouped into two categories:

Category 1: TINS that met the criteria as a group to avoid the 2016 PQRS payment adjustment, or in which at least 50% of eligible professionals in the TIN met the criteria to avoid the adjustment as individuals.

Category 2: TINs subject to the 2016 Value Modifier that do not meet the criteria for inclusion in Category 1. The modifier for Category 2 will be a negative 2.0% adjustment, in addition to any negative payment adjustment under PQRS.

Adapting to PQRS and Anesthesia Billing

PQRS is a complicated subject, and can be confusing even for veteran anesthesia billing teams. The ideal situation is one in which a provider turns to a third-party specialist that has experts well-versed in PQRS and all aspects of the program – especially how they apply to a billing situation.

PQRS isn’t something that can be ignored or set aside. It will have a major impact on the financial health of a practice and should be taken seriously. An anesthesia billing provider can help comply with PQRS and all that it requires.

Reviewing the Anesthesia Billing Guidelines You Need to Know

anesthesia billing guidelines

If you are an anesthesia provider in the state of Alabama, there are certain guidelines you need to be aware of in order to abide by all policies and regulations and ensure you are properly billing and collecting your claims.

Here are a few anesthesia billing guidelines your practice should follow.

Claim Filing

Effective for dates of service on or after January 1, 2014, Blue Cross Blue Shield of Alabama requires claims for anesthesiologists, CRNAs, and AAs to be billed under the name and National Provider Identifier (NPI) of the provider who actually rendered the service.

Blue Cross does not recognize “incident to” billing for anesthesia services. All providers should render services based on the scope of their particular license and requirements of the State of Alabama. Practitioners (anesthesiologists, CRNAs, and AAs) must each file for the professional anesthesia services they performed electronically on the electronic 837 Professional 5010.

For CRNA services performed on or after January 1, 2014, services will no longer be reimbursed through the hospital Blue Cross Cost Study. Both CRNA costs and charges should be excluded from the costs and charges reported in the hospital Blue Cross Cost Study.

Coding

Qualified anesthesia providers may bill directly for services using CPT anesthesiology codes 00100 – 01999. While some surgical CPT codes are appropriate to use when billing anesthesia services (e.g., CPT code 36620), the majority of anesthesia services should be billed using codes in the range of 00100 – 01999.

Base Units

The base unit is the value assigned to each CPT code and includes all usual services except the time actually spent in anesthesia care.

Pre-operative and post-operative visits are usually included. When multiple anesthesia services are performed, only the anesthesia services with the highest base unit value should be filed with total time for all services reported on the highest base unit value. The base units’ value should never be entered in the “units” field when filing claims.

Effective for dates of service on or after January 1, 2014, Blue Cross will utilize the Centers for Medicare & Medicaid Services (CMS) base unit values.

Anesthesia Time and Calculation of Time Units

According to CPT guidelines, anesthesia time begins when the anesthetists begins to prepare the patient in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance and the patient may be safely placed under post-anesthetic supervision.

Anesthesia time should be reported in minutes. Effective for dates of service on or after January 1, 2014, for all anesthesiologists, CRNAs, and AAs, one unit of time will be allowed for each 15-minute increment of anesthesia or a fraction thereof.

Reimbursement for time-based anesthesia is based on the following formulas:

Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier)

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

Anesthesia Performed under Medical Direction (QK, QX and QY modifiers)

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

An anesthesia “base unit” is the number of units assigned for the anesthetic management of surgical procedures using nationally recognized anesthesia base value standards. Base units are automatically calculated and should not be reported on the claim form. Blue Cross will utilize the CMS base unit values.

Anesthesia time should be submitted on the claim as total minutes. For example, one hour and nine minutes of anesthesia time is billed as 69 minutes. Blue Cross then converts minutes into 15-minute increments. This calculation would be four 15-minute time units and 9/15 of one unit. Total time units for this example are 4.6.

Blue Cross recognizes that the patient must be prepared immediately prior to induction and that some time may be spent immediately after the conclusion of the surgical procedure. Generally, no more than one unit should be necessary to prepare the patient for post-operative transfer to the recovery room. It is inappropriate to bill for anesthesia time while the patient is waiting in a holding area. If it is necessary for a more extensive service to be provided, documentation must be provided in the patient’s medical record to substantiate medical necessity. It is inappropriate to bill time units for services such as administration of blood products or antibiotics in the holding area, when such services could be provided in another area of the hospital or facility. 

Help with Following Anesthesia Billing Guidelines

If you need help with following the above guidelines – or any policies or regulations for billing in Alabama – contact a qualified and experienced third-party billings provider. We specialize in billing and coding for anesthesia providers and have the expertise and hands-on experience needed to navigate this process smoothly and efficiently.

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5 Tips for Effective Anesthesia Medical Billing

anesthesia billing company

Anesthesia medical billing can be complex – even daunting – at times. Practitioners are frequently faced with the challenge of not only billing and coding effectively, but also ensuring they comply with all relevant regulations and standards from several different payors.

To get the most from your billing system, here are five tips you can follow that can ensure your practice complies with regulations and maximizes its revenue.

Properly Calculate Time Units

Calculating time units and base units is an integral part of anesthesia medical billing, but it’s often prone to error.

Understanding proper time unit calculation means knowing the various formulas in play. Time units are added to whatever base units are assigned to the procedure to get the total units for billing purposes. For example, the formula used by commercial insurers is Base Units + Time Units + Physical Status Modifier = Total Units.

To calculate time units, take the total number of minutes spent on a procedure (start time to stop time, accounting for any breaks) and divide by 15. Any segment over seven minutes is rounded up to the next 15 minutes. So, a procedure that lasts from 8:00am to 9:08am would equal five units, not four. Many forms, however, require that you list the actual minutes (in this case, 68 minutes).

Remember that anesthesia time is considered the period of time in which the practitioner is present with the patient.

Understand Your Modifiers

Any anesthesia medical billing specialist should know modifiers intimately, as they play a major role in getting properly reimbursed.

There are several modifiers, including but not limited to the following:

  • AA: Anesthesia Services performed personally by the anesthesiologist
  • AD: Medical supervision by physician; more than four concurrent anesthesia procedures QK:  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.
  • QY: Medical direction of one CRNA/AA by an anesthesiologist
  • QX: CRNA/AA service with medical direction by an anesthesiologist
  • QZ: CRNA services without medical direction by an anesthesiologist

Modifiers are specific and must be carefully applied. Many denied or delayed claims were due to incorrect or missing modifiers.

Use Correct Physical Status Modifiers

As discussed above, total unit calculations involve adding physical status modifiers, which report the patient’s overall physical health.

Modifiers include:

  • P1. A patient in normal health (0 units)
  • P2. A patient with a mild systemic disease (0 units)
  • P3. A patient with a severe systemic disease (1 unit)
  • P4. A patient with a severe systemic disease that is life-threatening (2 units)
  • P5. A patient whose survival without the operation is not expected (3 units)
  • P6. A patient who has been declared brain-dead and whose organs are being removed for donation (0 units)

All insurers (except for Medicare) typically allow for additional physical status modifiers and total units if the patient has chronic conditions or other high-risk factors.

Anesthesia medical billing specialists must not miss or misuse physical status modifiers. Not only can this result in less revenue for a practice, it can also result in running afoul of compliance and triggering audits.

Properly Document All Qualifying Circumstances

Providers have the option of submitting qualifying circumstances to payors if the service provided was deemed necessary and reasonable for the patient’s circumstances. Leaving off these qualifying circumstances can dramatically reduce the potential for reimbursement, which can cause a loss of revenue for a provider.

For example, the +99100 code describes anesthesia that was provided for a patient who is younger than one year old or older than 70 years old. That is worth one additional unit of anesthesia. The +99140 code – anesthesia that is complicated by an emergency condition – is worth two units. At the top end are +99116 (anesthesia complicated by total-body hypothermia) and +99135 (anesthesia complicated by controlled hypotension), which are both worth five units.

Significant revenue potential can be lost without proper documentation and reporting of these qualifying circumstances. Failure to do so is one of the main reasons providers frequently miss out on all of their revenue potential.

Hire an Anesthesia Medical Billing Contractor

The best way to ensure proper compliance and complete collection of all potential revenue is to hire an anesthesia medical billing contractor that has the experience and expertise to specialize in billing and coding.

Doing so relieves overhead, since in-house staff can be reduced, and reduces overall costs in the form of better collections and payments. You can also avoid denied claims or delays in payments more successfully than most practices can do with in-house staff.

Contact a contractor to learn more tips for proper coding and billing for anesthesia providers.

Anesthesiologists Announce Opposition to Pending Bill in Congress

physician anesthesiologists
The “Veterans Health Care Staffing Improvement Act”, S. 2279, is a piece of legislation that could have extensive repercussions for veteran health care, according to the nation’s largest anesthesiology trade group.

The American Society of Anesthesiologists (ASA) announced this month that they have exercised caution about passing S. 2279 because of one provision the Society calls “misguided”. The provision in question would remove physician anesthesiologists from surgery and will replace them with nurses instead. The end result, according to the Society, would be jeopardy for veterans’ safety and a lower standard of care.

That isn’t the main goal of the bill; the stated purpose of the act is to ease the transition of military health care providers to the Department of Veterans Affairs. But as so often happens with legislation, the act contains a provision that the ASA believes is dangerous.

In short, the bill, if passed, would “eliminate the existing and proven model of care where physician anesthesiologists and nurse anesthetists work together as a team”, according to an ASA press release. ASA has raised concerns over a provision that would grant independent practice for all APNs, stating that nurse anesthetists shouldn’t be included in the mandated “full practice authority” initiative.

Sponsors of the bill state that the provision is to relieve overstaffed VA hospitals. But according to the ASA, there is no shortage of either physician anesthesiologists or nurse anesthetists in the VA system – leading some in the industry to question the provision.

Right now, the bill has been referred to the Committee on Veterans’ Affairs in the Senate. It has not progressed out of committee and is unlikely to before the end of the year, due to the Senate’s holiday calendar. There is no indication from the White House regarding its intent to sign or veto the bill.

For more information, please consult the press release from the ASA here.

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Anesthesiologists Announce Opposition to Pending Bill in Congress

The “Veterans Health Care Staffing Improvement Act”, S. 2279, is a piece of legislation that could have extensive repercussions for veteran health care, according to the nation’s largest anesthesiology trade group. The American Society of Anesthesiologists (ASA) announced this month that they have exercised caution about passing S. 2279 because of one provision the Society […]