Www.medac.com Society Hill Anesthesia (Riddle Memorial Hospital) 2012 Compliance Education.

www.medac.comwww.medac.com

Society Hill Anesthesia (Riddle Memorial Hospital)

2012 Compliance Education


Topics of Discussion

Provider Documentation Report CardsDocumentation FeedbackPost-Operative Pain Billing ClarificationCMS Incentive ProgramsHIPAA / HITECH AUDITS2012 Anesthesia Specific Changes


Why is it important to document properly and keep up with the

changes?RACs (Recovery Audit Contractors)MICs (Medicaid Integrity Contractors)FERA (Fraud Enforcement & Recovery Act)ZPICS (Zone Program Integrity Contractors)HITECH (Health Information Technology for Clinical & Economic Health) Act

OIG Target Areas 2012


Group Summary of Documentation Errors & OmissionsJanuary 2011 – December 2011

Information Request Type

Total % Based on 2011 Total Cases Billed

Procedure Code 646 6.4

Diagnosis Code 125 1.2

Start/ Stop Time 190 1.9

Attending 66 0.7

Anesthesia Type 94 0.9


Information Requests by Provider- Summary(01/01/2011 to 12/31/2011)

Physician Px Dx S/S ATD ANES

CERCEGA, MIRCEA 1 0 0 0 1

GLASSER, STEVEN 6 0 4 1 1

GOLDSTEIN, ALLAN 1 0 0 0 0

HAAS, ALLEN 3 2 2 4 1

HAIKEN, JEFFREY 2 0 0 1 0

INGERSOLL WENG, E 77 11 23 5 20

LIPPMAN, DEBORAH 1 1 0 0 0

MAHADEVIAH, ANN 96 25 26 3 8

NASSIF, ALLISON 4 0 3 1 0

OFLYNN, RICHARD 73 9 14 5 3

OLIVA, JOSEPH 0 0 1 0 0

PHARO, GREGORY 13 6 1 6 4

RICCO, ERNEST 80 16 28 6 5

SHROPSHIRE, DIANE 0 0 0 0 0

SIRIANNI, ARCHIE 85 17 21 2 17

SMITH, JENNIFER 6 2 6 0 1

SOCH, JASON 56 10 15 2 7

SWIFT, DOUGLAS 2 0 0 0 0

THORNTON, ANTHONY 0 0 0 0 0

VELOSO, KATHLEEN 33 5 10 1 2

VILLASIS, HENRY 97 13 21 21 22

YOUNG, MARIE 0 0 0 0 0

ZENTNER, MIRIAM 10 1 15 7 2


Top Documentation Errors• Anesthesia end time not given

• Missing/Incomplete/incorrect procedure– Missing site/approach for abdominal procedures (Upper or lower abdomen) – Missing approach for ureter lithotripsy (Proximal/ distal) – Not documenting whether multiple levels were done or whether instrumentation was involved for

spinal arthrodesis, ACDF, and other spinal procedures– One vs. two lung ventilation – Site/type of fracture not given– Site/depth of debridement not given– Open/closed procedure not specified– Non-standard abbreviation utilized (e.g. UE for EGD, CLP for Colonoscopy with polypectomy)– Type of hernia not given.

• Missing or incomplete diagnoses– “Rule out” & “possible” Dxs are non-payable Dxs for anesthesia providers. Document presenting signs

or symptom(s) instead: e.g. document “R Lower Quadrant Pain” instead of “R/O Appendicitis” – Medical necessity dx. not provided (PA Medicare has a MAC policy). Need drugs given for MAC if no

MAC diagnosis is available so V58.83 can be used

• Anesthesia type not documented.

• Missing relief time documentation. • Provider placing an invasive line is not documented.

• Illegibility of record/part of record


Documentation Feedback• Missing site for Abdominal procedures (Exploratory laparotomy, lysis of adhesions etc.)

– Upper abdomen – 7 units– Lower abdomen – 6 units

• Missing technique for Spinal procedures (Lumbar)– With instrumentation or multiple vertebral levels – 13 units– Without instrumentation – 8 units

• Missing technique for Spinal procedures (Cervical)– With instrumentation or multiple vertebral levels– 13 units– Without instrumentation– 10 units

• Missing site for Cystourethroscopy– 5 units– Kidney, upper 1/3 ureter, or renal pelvis involvement – 7 units

• Missing information on 1 vs. 2 lung ventilation– One lung ventilation– 15 units– One lung ventilation– 12 units


Top Documentation Errors• Missing site/approach for abdominal procedures (Upper or

lower abdomen) • Missing approach for ureter lithotripsy (Proximal/ distal) • Missing documentation as to whether Implantable Cardioverter

Defibrillators (AICD) were tested• “Rule out” & “possible” Dxs are non-payable Dxs for anesthesia

providers. Document presenting signs or symptom(s) instead: e.g. document “R Lower Quadrant Pain” instead of “R/O Appendicitis”

• Diagnoses not being documented on anesthesia record at all• Unclear documentation as to whether the spinal is the primary

anesthetic or utilized for post-op pain.• Not documenting whether multiple levels were done or whether

instrumentation was involved for spinal arthrodesis, ACDF, and other spinal procedures


Documentation Feedback• Missing site for Abdominal procedures (Exploratory laparotomy, lysis of adhesions etc.)

– Upper abdomen – 7 units– Lower abdomen – 6 units

• Missing technique for Spinal procedures (Lumbar)– With instrumentation or multiple vertebral levels – 13 units– Without instrumentation – 8 units

• Missing technique for Spinal procedures (Cervical)– With instrumentation or multiple vertebral levels– 13 units– Without instrumentation– 10 units

• Missing site for Cystourethroscopy– 5 units– Kidney, upper 1/3 ureter, or renal pelvis involvement – 7 units

• Missing information on AICD if testing was performed– With Testing– 10 units– Without Testing– 7 units


How Uncle Sam views postoperative epidural blocks

• Medicare views postop pain control as “bundled” into the surgeon’s fee.

• Consequently, to prove medical necessity, postop pain blocks must be “requested” by the surgeon.

• A written order by the surgeon is cleanest, but Medicare will accept a note by you documenting “surgeon request”.


Invasive lines (arterial lines, central lines, etc.) and

post-op pain procedures (blocks, catheters, etc.) are

coded and billed AS SEPARATE PROCEDURES and ARE

PAID AS A SEPARATE FLAT FEE, in addition to the

anesthetic for the case.

Invasive line Placement


In other words….

IF YOU PLACE A LINE OR P.O.P. BLOCK OR CATH OR AN INVASIVE LINE PRIOR TO INDUCTION OF THE PRIMARY ANESTHETIC, YOU CANNOT REPORT THE TIME ASSOCIATED WITH PLACING THE LINE OR P.O.P PROCEDURE.

Except….

Invasive line Placement


ONLY AFTER INDUCTION OF THE primary anesthetic has been

administered, may you continue to report and bill for anesthesia

time concurrently with the placement of invasive lines and/or

regional blocks and still be paid both the flat fee and the time

associated with placing the line or post-op-pain procedure.


Anesthesia & Post-op Pain Management

Question: Should the time spent placing nerve blocks for postoperative pain control, spinals, arterial lines, etc. be deducted from main anesthesia start and stop times?Would the time spent placing these items need to be deducted from the anesthesia time for the operation? Is there a difference between the arterial line, etc being placed prior to the patient ‘going to sleep’ or after in regards to discounting this ‘placement time?

Answer: “The Anesthesia guidelines in the CPT codebook indicate that placement of monitoring devices such as central venous lines, arterial lines, and Swan-Ganz catheters are separately reportable from an anesthesia service. Placement of these monitoring devices have no time associated with them. If a nerve block or epidural is performed for the purpose of postoperative pain management and not as part of the anesthesia for the surgical procedure, then it too is reported separately. When these procedures are performed before the start of anesthesia time, the time spent on them should not be added to the reported anesthesia time because they are separate and distinct from the anesthesia service. If the procedure is performed after induction of the primary anesthetic, it is not necessary to deduct the time spent on the procedure from reported anesthesia time.”

CPT Assistant, Volume 17, Issue 5, May 2007 REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA Committee of Origin: Economics (Approved by the ASA House of Delegates on October 17, 2007 and last updated on September 2, 2008)

ASA Position On Post-Op Pain

The time spent on pre- or postoperative placement of the block is separated and not included in reported anesthetic time.

Post surgical pain blocks are most frequently placed before anesthesia induction or after anesthesia emergence. When the block is placed before anesthesia time starts or after it has ended, the time spent placing the block should not be included in reported anesthesia time; this is true irrespective of what level of sedation and monitoring is provided to the patient during that block placement. Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time.

Time spent on the placement of a post surgical pain block that occurs prior to induction or after emergence is separate and not included in reported anesthesia time.

In such cases, it may be necessary to report discontinuous anesthesia time. Sedation given expressly to facilitate placement of the block should not be included in reported anesthesia time.

REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA- Committee of Origin: Economics (Approved by the ASA House of Delegates on October 17, 2007 and last updated on Sept 2, 2008)


CMS 2012 Clarification: Separate Billing of Post-Operative Pain Blocks & Catheters

• “Clearly a preoperatively administered epidural or nerve block for postoperative pain will provide some analgesia during the operative procedure. If the patient also receives GENERAL anesthesia for the surgical procedure reported with a 0XXXX [anesthesia] code, a preoperatively administered epidural or nerve block may be separately reported.

• However, if the patient does not require GENERAL anesthesia for the surgical procedure, the preoperatively administered epidural or nerve block for postoperative pain management provides intraoperative pain management and would be included in the 0XXX code and should NOT BE REPORTED SEPARATELY.” (Niles R. Rosen, M.D. – Medical Director, NCCI, MUE)


CMS 2012 Clarification: Separate Billing of Post-Operative Pain Blocks & Catheters

• Therefore, if there is only a regional anesthetic or a MAC, a separate post-op pain block that is administered preoperatively and which provides any analgesia will be bundled and not separately reportable. The anesthetic must be a general anesthetic in order for the preoperatively placed post-op pain block to be separately reportable.

• For billers and coders, in order to bill separately for a post-op pain block which is administered pre-operatively, the anesthesia record will need to reflect the type of anesthesia as a general, not MAC, and not Regional.


When not to bill separately for a regional block procedure

• If the regional block (e.g. epidural, brachial plexus block, etc.) is serving as the primary anesthetic technique, then a separate bill for that procedure is not allowed.

• In this circumstance, only anesthesia time is reported and billed for. (In this case, use only the anesthesia record to document the procedure.)


Incentive Programs

PQRS (Physician Quality Reporting System) E-Prescribing

Two new G codes for exemptions

EHR Incentive Program New Value Based Payment Modifier


Incentive ProgramsPQRS

No new PQRS measure for 2012; however,

The bonus payment for 2012 will be 0.5% (down from the 2011 bonus payment of 1%)

The PQRS bonus payment will convert to a PQRS penalty in 2015 (1.5% penalty in 2015 and in 2016 and beyond, the penalty will increase to 2%.


Incentive ProgramsEHR incentive program

EHR incentive program- Are anesthesiologists eligible? NO!!!

Initial regulations stated that if 90% or more of cases are inpatient, anesthesiologist is not eligible for incentive/ or penalty.For most anesthesiologists, 10% of their cases are in outpatient or ASC settingOn Jan 13, 2012, CMS issued draft regulations that exclude anesthesia practices from the EHR Bonus incentive program!Rationale: Gov’t wants to avoid “double dipping” – paying the hospital for its EHR system and paying the hospital based anesthesiologist for another system.


Incentive Programs E-Prescribing

E-PrescribingTo avoid the 2013 penalty (1.5%) a provider must report 10 eRxs in the first half of 2012 or 25 in all of 2011to avoid the 2014 penalty (2%) a provider must report 10 eRxs in the first half of 2013 or 25 in all of 2012for purposes of avoiding the 2013 or 2014 penalty a provider will be allowed to report a specific numerator on any claim and/or file one of four hardship exemptions

(a) limited internet, (b) limited pharmacy, (c) prohibited by law; (d) less than 100 prescriptions in the first 6 months.Exclusion from Participation A provider is not subject to the penalty if any one of the following applies:

(a) Denominator (= outpatient E/M codes) represents less than 10% of total Medicare allowable (Jan –Jun);

(b) less than 100 cases (Jan – Jun) with denominator codes; (c) not an MD, DO, podiatrist, NP, or PA by 6/30/12; or

(c) do not have prescribing privileges (must report G8644 at least once on eligible claim before 6/30/12)


Incentive Programs (contd.)

New Value Based Payment Modifier

New Value Based Payment Modifier (in 2015)The new modifier will pay more to providers that provide better services at less cost than their peers. Cost and quality measures are to be adopted by CMS No information available yet exactly how the modifier will be applied for anesthesia


HIPAA Audits

In accordance with the American Recovery and Reinvestment Act of 2009 (ARRA), Section 13411 of the HITECH Act, the Department of Health and Human Services (DHHS) has contracted with KPMG to perform 150 HIPAA audits between November 2011 and December 2012.

Every covered entity (i.e., Providers, Provider Groups, Hospitals, ASCs, Physician Offices, Clinics) and business associate (e.g., Consultants, Billing Companies, Collection Agencies, Auditors, etc.) is eligible for an audit.

When a covered entity is selected for an audit, the Office of Civil Rights (OCR) will notify the covered entity or business associate in writing between 30 and 90 days prior to the anticipated onsite visit.


Anesthesia Specific Changes


ASA Crosswalk Changes Procedures/codes with higher paying (base unit) crossover :

CPT code 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum)

The old crossover code options for this procedure were 00400, 00920 and 00940 (3 base units). The new crossover code for this procedure crosses to the radical perineal ASA anesthesia code 00904 - which is 7 base units. There are no alternate crosses for 2012

CPT code 24155 (Resection of elbow joint-arthrectomy). The old crossover code for this procedure was 01740 (4 base units). The new

crossover code for this procedure is 01756 - which is 6 base units. There are no alternate crosses for 2012;

CPT code 57426 (Revision including removal of prosthetic vaginal graft, laparascopic app) The old crossover code for this procedure was 00940 (3 base units). The new

crossover code for this procedure crosses is 00840 - which is 6 base units. There are no alternate crosses for 2012.


ASA Crosswalk Changes (contd.)

Procedures/codes with lower paying (base unit) crossover :CPT code 48511 – External drainage, pseudo cyst of pancreas; percutaneous. The old

crossover code for this procedure was 00790 (7 base units). The new (lower paying base unit) crossover code for this procedure crosses to ASA anesthesia code 00700 - which is 4 base units. There are no alternate crosses for 2012

CPT code 49041 – Drainage of subdiaphragmatic or subphrenic abscess; percutaneous. The old crossover code for this procedure was 00790 (7 base units). The new (lower paying base unit) crossover code for this procedure crosses to ASA anesthesia code 00700 - which is 4 base units. There are no alternate crosses for 2012.



Procedures/codes with changed primary crossover code (No change in Base Units):

CPT code 23140 (Excision or curettage of bone cyst or benign tumor of clavicle or scapula)

CPT code 23145 (Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft -includes obtaining graft)

CPT code 23146 - Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft.

The primary crossover code for these procedures is 00450 and the alternate crossover code is now 01630 (both codes are still 5 base units).



Procedures/codes with changed code definition (No change in Base Units):

CPT code 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve -transforaminal placement)

The primary crossover code for these procedures is 00300 and the alternate crossover code 00400 has been deleted.



ASA concluded that “ANESTHESIA IS NOT TYPICALLY REQUIRED” for the following procedures/codes:

CPT (Skin) Codes 11055, 11056 and 11057 (Paring or cutting of benign hyperkeratotic lesion(s)CPT (Skin) Codes 11950, 11951, 11952, and 11954 (Subcutaneous injection of filling material

(e.g. collagen)CPT (Skin) Codes 15788, 15789, 15792, and 15793 – Chemical peel, facial or non-facial,

epidermal or dermalCPT (skin) code 17340 (Cryotherapy (CO2 slush, liquid N2) for acne) CPT (skin) code 17360 (Chemical exfoliation for acne (e.g., acne paste, acid) CPT (skin) code 17380 (Electrolysis epilation, each 30 minutes) CPT ( Bone/Tissue Graft/Implant) code 20950 (Monitoring of interstitial fluid pressure (includes

insertion of device, e.g., wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome)

CPT ( Bone/Tissue Graft/Implant) code 20974 (Electrical stimulation to aid bone healing; noninvasive (nonoperative)

CPT (Head Prostheses) codes 21076, 21077, and 21079 (Impression and custom preparation; surgical obturator, or orbital, or interim obturator prostheses, respectively)


ASA RVG ChangesComment Clarified for ASA 01844

01844 (Anesthesia for vascular shunt, or shunt revision, any type (e.g. dialysis) The new comment clarifies that this code is not to be used for

“excision or removal of infected grafts”. RVG instructs to “report an anesthesia code from the affected

arterial anatomical location”.


ASA RVG ChangesI.C Designation Codes

Base Unit assignments deleted for single/continuous epidural/spinal injection codes, facet injection codes and transforaminal epidural codes

2012 ASA RVG deleted base unit assignment codes for CPT codes 62310, 62311, 62318, 62319, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, and 64495, 64633-64636

These codes have IC (Individual Consideration) designation– May affect 3rd party payer reimbursement. – Recommend to include in contract to avoid the risk of reduced payments


ASA RVG ChangesAnesthesia for Chronic Pain Procedures

In 2012 ASA stated conditions supporting anesthesia for minor pain procedures to be as follows: “major co-morbidities and mental or psychological impediments to cooperation are examples”.

Sympathetic blocks, Radiofrequency, discography, percutaneous discectomy and trial spinal cord stimulator, continuous catheters may warrant IV sedation, and at times MAC

MAC anesthesia for diagnostic/therapeutic injections and MAC anesthesia for GI cases are RAC targets. It is important that one ensures that “conditions supporting anesthesia for these procedures” are well documented.


In Summation

The Feds are creating new ways to target providersNew laws & regulations to get at youNew fines to assess against you

The Feds are creating new ways to control providers“Incentive” (penalty) programsMandatory compliance plan

Scrupulous attention to compliance is no longer an option!

www.medac.comwww.medac.comwww.medac.com

Questions & Answers Session

Date post:	27-Dec-2015
Category:	Documents
Upload:	derek-berry
View:	225 times
Download:	5 times

Www.medac.com Society Hill Anesthesia (Riddle Memorial Hospital) 2012 Compliance Education.

Documents