How to eliminate anesthesia claims filing errors

The following information is to provide awareness and clarification to providers and billers of Anesthesia services to eliminate claim filing errors.

In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.

Coverage of Monitored Anesthesia Care (MAC)

During monitored anesthesia care (MAC), close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.

The following requirements for this type of anesthesia should be the same as for general anesthesia with regard to:

Ø  The performance of preanesthetic examination and evaluation.

Ø  The prescription of the anesthesia care required.

Ø  The completion of an anesthesia record.

Ø  The administration of necessary medications and the provision of indicated postoperative anesthesia care.

For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.

The presence of an underlying condition alone, as reported by an ICD-9-CM diagnosis code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.

Therefore, in cases were the anesthesia is usually provided by the attending surgeon and are included in the global fee and are not separately billable, MAC provided by anesthesia personnel may be necessary due to active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications.

If this is your case, the use of anesthesia modifiers is required as follows:

ü  G8 anesthesia modifier – used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only:  00100, 00300, 00400, 00160, 00532 and 00920.

ü  G9 anesthesia modifier – represents “a history of severe cardiopulmonary disease” and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.

Additionally, anesthesia physical status modifiers must be appended to indicate the clinical condition of the patient receiving MAC: 

P1 – healthy individual with minimal anesthesia risk, 

P2 – mild systemic disease, 

P3 – severe systemic disease with intermittent threat of morbidity or mortality, 

P4 – severe systemic illness with ongoing threat of morbidity or mortality, 

P5 – premorbid condition with high risk of demise unless procedural intervention is performed.

Special conditions and/or criteria must be supported by documentation in the medical record.

Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic.

Documentation requirements

Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the patient’s condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated or markedly invasive).

The medical record should include a pre-anesthesia evaluation including a history and physical exam.

The medical record should include evidence of continuous monitoring of the patient’s oxygenation, ventilation, circulation and temperature.

The medical record should include a post-anesthesia evaluation of the patient including any unusual events or complications and the patient’s status on discharge.

Billing Tips

Anesthesia for Multiple Surgeries
Payment may be made for the anesthesia services provided during multiple or bilateral surgery procedures. When billing anesthesia services associated with multiple or bilateral surgeries, report only the anesthesia procedure with the highest base unit. Report the total time in minutes for all procedures on one detail line item.

Administration of Anesthesia by the Surgeon
Reimbursement for anesthesia performed by the operating surgeon is included in the allowance of the surgical procedure rendered during the same operative session. Separate payment is not allowed when surgeon performs the surgical procedure and performs local or surgical anesthesia.
No claim should be submitted for the anesthesia service.

Anesthesia Time

Anesthesia time begins when the anesthesiologist starts to prepare the patient for the procedure. Normally, this service takes place in the operating room, when monitoring start. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

Anesthesia unit calculation

To calculate the amount of anesthesia units, divide the total anesthesia time in minutes by 15.

Time in Minutes	Anesthesia units
1-15	1
16-30	2
31-45	3
46-60	4

 

**Note: If the surgery is non-covered, the anesthesia is also non-covered**

 Source: Medicare Claims Processing Manual, Chapter 12, Section 50(e) and Medicare Local and National coverage determination.

Trigger point Injections, Coverage Indications, Documentation Requirements, Limitations and Coding TIPS

Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. Trigger point injections are indicated in symptomatic trigger points.

Myofascial trigger points are "small, circumscribed, hyperirritable foci in muscles and fascia, often found with a firm or taut band of skeletal muscle. These trigger points produce a referred pain patterned characteristic for that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with every perpetuating factor. These single muscle syndromes is responsive to appropriate treatment, which includes injection therapy.

The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain. Injection is achieved with needle insertion and the administration of agents, such as local anesthetics, steroids and/or local inflammatory drugs.

ü  As initial (diagnostic) or the only therapy when a joint movement is impaired, such as when a muscle cannot be stretched fully or is in fixed position and/or when joint movement is mechanically blocked as is the case of the coccygeus muscle.

ü  As treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., exercise, use of medications, stretch and spray.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon the detailed history and thorough examination. The following diagnostic criteria are needed:

Major criteria. All four must be present to establish the diagnosis.

A.    Regional pain complaint

B.    Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point

C.    Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it

D.    D. Some degree of restricted range of motion, when measurable.

Minor criteria. Only one of four needed for the diagnosis.

A.    Reproduction of referred pain pattern by stimulating the trigger point

B.    Altered sensation by pressure on the tender spot

C.    Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot

D.    Pain alleviated by stretching or injecting the tender Spot

After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:

1.     Medical management, which may include consultation with a specialist in pain medicine.

2.     Medical management that may include the use of analgesics and adjunctive medications, including anti-depressant medications, shown to be effective in the management of chronic pain conditions.

3.     Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of motion and deep muscle massage.

4.     Active physical therapy, including active range of motion, exercise therapy and physical conditioning. Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible).

5.     Manipulation therapy.

6.     Psychiatric evaluation and therapy.

7.     A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated.

8.     Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points.

Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long term benefits.

An injection of a trigger point is considered medically necessary when it is currently causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed.

The goal is to treat the cause of the pain and not just the symptom of pain.

Documentation Requirements

All documentation must be maintained in the patient’s medical record and available upon request.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

For the treatment of established trigger points, the patient’s medical record must have:

o    Documentation of the physical findings leading to diagnosis of the trigger point.

o    Documentation of the evaluation/ process of arriving at the diagnosis of the trigger point in an individual muscle should be clearly documented in the patient’s medical record 

o    The reason for the trigger point injection, and whether it is being used as an initial or subsequent treatment for myofascial pain, as well as the appropriate diagnosis code should be documented.

o    The involved muscle group(s) must be documented in the patient’s medical record as well as the number of trigger points injected. A diagram with an "X" or other similar annotation is not adequate documentation.

o    Documentation of the reason(s) for selecting this therapeutic option.

o    Diagnosis codes from the “ICD-9-CM Codes that Support Medical Necessity” must be used to support the specific muscles injected. Generalized diagnoses like low back pain, lumbago, etc. will not be covered.

o    If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections must be documented in the patient's medical record.

o    The health plan may request records when it is apparent that patients are requiring a significant number of injections to manage their pain.

o    Documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s).

Limitations

Acupuncture is not covered by Medicare, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service). See your private health plan policy for coverage.

Providers of acupuncture services must inform the beneficiary that their services will not be covered as acupuncture is not a Medicare benefit.

Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered.

"Dry needling" of trigger points is a non-covered procedure since it is considered unproven and investigational.

Coding Tips

Only one code from 20552 or 20553 should be reported on any particular day, no matter how many sites or regions are injected.

The CPT codes for trigger point injections use the phrase "muscle group(s)" as a group of muscles that are contiguous and that share a common function, e.g., flexion, stabilization or extension of a joint. Trigger points that exist in muscles that are widely separated anatomically and that have different functions may be considered to be in separate muscle groups.

When a given site is injected, it will be considered one injection service, regardless of the number of injections administered.

Source: Centers for Medicare and Medicaid Services Local and National Coverage Determinations 

When Peripheral Nerve Blocks are Considered Medically Necessary and Documentation requirements

Pain management billing includes both general and more difficult procedures that sometimes require a specialist. When billing for pain management you need to know the differences between the following terms:

Chronic pain is a persistent pain during a long term (More than 6 month).

Acute pain begins suddenly and typically doesn’t last less than 6 month).

Diagnostic phase is the identification of the nature and cause.

Therapeutic phase refers to the treatment of the findings in the diagnostic phase.

What do payers look for?

ü  Complete and legible medical notes

ü  Reason for the encounter and relevant history, physical examination, findings, and prior diagnostic test results

ü  The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented

ü  Assessment, clinical impression, or diagnosis

ü  Medical plan of care

ü  Date and legible identity of the observer.

What do payers want and why?

Health care insurance companies may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

ü  That services furnished have been accurately reported.

ü  The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

ü  Safe and effective.

ü  Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).

ü  Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Ø  Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

Ø  Furnished in a setting appropriate to the patient's medical needs and condition.

Ø  Ordered and furnished by qualified personnel.

Ø  One that meets, but does not exceed, the patient's medical needs.

Ø  At least as beneficial as an existing and available medically appropriate alternative.

When Peripheral Nerve Blocks are Considered Medically Necessary?

Peripheral nerve blocks will be considered medically reasonable and necessary for conditions such as the following diagnostic and therapeutic purposes:

1. When the patient’s pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation.

2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome.

3. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear.

4. When an occipital nerve block is used to confirm the clinical impression of the presence of occipital neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as the result of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or bilateral, constant or intermittent. Nerve injury secondary to a blow to the back of the head or trauma to the nerve from a scalp laceration can also cause this condition. Most commonly it is caused by an entrapment of the occipital nerve in its course from its origin from the C2 nerve root to its entrance into the scalp through the mid portion of the superior nuchal line. Blockage of the occipital nerve can confirm the clinical impression of occipital neuralgia particularly if the clinical picture is not entirely typical. If only temporary relief of symptoms is obtained, neurolysis of the greater occipital nerve may be considered via multiple techniques including radiofrequency, and cryoanalgesia. In addition, the lesser and third occipital nerves can be involved in the pathology of headaches, and can be treated in a similar manner.

5. When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve. Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a syndrome of pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When the history and examination point to the diagnosis, a suprascapular nerve block leading to relief of pain can confirm it. This may be followed by injection of depository steroids that sometime provide lasting relief.

6. When the trigeminal nerve is blocked centrally at the trigeminal ganglion, along one of the three divisions or at one of the many peripheral terminal branches (i.e., supraorbital nerve).

7. Nerve blocks as preemptive analgesia

The signs and symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. More than three injections per anatomic site (e.g., specific nerve, plexus or branch as defined by the CPT code description) in a six month period may not be medically necessary.

More than two anatomic sites (e.g., specific nerve, plexus or branch as defined by the CPT code description) injected at any one session may not be medically necessary.

If the patient does not achieve progressively sustained relief after receiving two to three repeat peripheral nerve block injections on the same anatomical site, then alternative therapeutic options should be explored.

General Documentation Requirements

ü  Exact Procedure structure

ü  Treatment details (E.g. who administer the treatment and the medication being injected including route, dose, etc…)

ü  If more than one procedure is performed on the same DOS provide a detailed procedure note.

ü  The patient response to the treatment.

ü  If applicable document clearly the use of image guidance (e.g. fluoroscopy, ultrasound, etc…) and include the equipment description.

** Some devices are incidental to the main procedure and not separately billable (e.g. handheld ultrasound devices) **

Specific Documentation Requirements

Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

ü  Whether the block was a diagnostic or therapeutic injection

ü  Pre- and post-procedure evaluation of patient

ü  Patient education

When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record.

Please Note: In addition to the general documentation rules you must comply with federal and state rules depending on the procedure you are billing.

You can help fight fraud, waste and abuse

The total health care spending amount is estimated to exceed $3 trillion annually in the United States. The FBI estimates as high as 10% of our annual health care expenditure is lost each year due to health care fraud. See the following links for additional info. (http://www.cdc.gov/nchs/fastats/health-expenditures.htm and http://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud )
This results in higher costs for everyone:

·         Higher premiums and out of pocket expenses and reduced benefits

·         Customers experience higher cost of providing benefits to employees

·        
Providers experience higher operating costs

·        
Everyone suffers from a more rapid depletion of money from the Medicare trust fund and increased taxes

Common Healthcare Fraud, Waste and Abuse Schemes

Member

ü  Doctor Shopping

ü  Alteration of claims

ü  Lending the health plan card to another non-covered person 

Medical Identity Theft

 

ü  Stolen cards used to file fraudulent claims

ü  Stolen provider’s tax identification number used to file fraudulent claims

ü  The use of a stolen provider’s prescription pad

Provider

             

ü  Billing for services not rendered or rendered by a third party

ü  Adding modifiers to claims to acquire additional reimbursement

ü  Billing for non-covered services using an incorrect procedure or diagnosis code

Long Term Care

          

ü  Changing the member’s physical or mental status on the application or during the assessment evaluation to qualify for benefits.

ü  Provider or facility billing for more care and hours of services than are actually rendered.

ü  Facility billing for services of an individual who was not a client of the facility.

ü  Billing by an unlicensed or phantom facility.

Pharmacy

          

ü  Filling less than the prescribed quantity of a drug

ü  Pharmacy bills for brand name when generic drugs are dispensed

ü  Adulterated drugs through black market purchases

ü  Kickbacks, inducements, and other illegal remuneration

Accident and Disability

          

ü  Falsifying an injury or the extent of an injury in order to receive permanent or temporary disability benefits. 

ü  Continuing to submit claims for disability benefits where the insured is no longer disabled.

ü  Provider submits additional medical documentation misrepresenting the information to support false claims.

Consequences

There are severe consequences for committing fraud, waste, and abuse, the severity of which depends on the violation.

These can include:

• Civil money penalties

• Criminal conviction/fines

• Civil prosecution

• Imprisonment

• Loss of provider license

• Exclusion from federal health care programs

• Termination of provider contract