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Articles by Kelly Dennis

 Please note these are dated articles. Up-to-date policies AND CODES should be referenced  in conjunction with this information.  

Permission is granted to print and share, provided author is credited




​Communique, Fall 2019
Documenting Anesthesia Services
https://www.anesthesiallc.com/publications/communiques/104-communique/past-issues/fall-2019/1256-documenting-anesthesia-services
 

Summer 2018 Communique
The Winning Strategy for Billing Invasive Monitoring
 
http://www.anesthesiallc.com/publications/blog/entry/the-winning-strategy-for-billing-invasive-monitoring

March, 2017, Healthcare Business Monthly, Quality Reporting for Anesthesia Services:  Then and Now
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA,  ACS-AN

www.aapc.com/blog/37862-quality-reporting-for-anesthesia-services-then-and-now/

American Academy of Professional Coders, Healthcare Business Monthly, January 2016
Conform to Your Particular Anesthesia Documentation Rules

www.aapc.com/blog/33191-33191/

Winter 2016 Communique
2016 Coding Updates for Anesthesia
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I

http://www.anesthesiallc.com/component/content/article/89-communique/current-issue/winter2016/861-2016-coding-updates-for-anesthesia


Winter 2014 Communique

Reporting Postoperative Pain Management in 2014

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I

http://www.anesthesiallc.com/index.php/publications/communique?id=679

AAPC Articles may require membership to access



Communique, Summer 2014
Field Avoidance and Special Positioning

www.anesthesiallc.com/about-abc/18-communique/past-issues/summer-2014/65-field-avoidance-and-special-positioning

American Academy of Professional Coders, Healthcare Business Monthly, Dec. 2014
An Insider’s View:  Field Avoidance and Special Positioning

www.aapc.com/blog/28701-an-insiders-view-field-avoidance-and-special-positioning/

September, 2013, AAPC  Coding Edge, Managing Post Operative Pain is a Joint Effort

By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA,  ACS-AN

http://news.aapc.com/index.php/2013/09/managing-postoperative-pain-is-a-joint-effort/

​

February, 2011 AAPC  Coding Edge, Understand Payer Guidelines to Keep Up-to-date with Anesthesia
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA,  ACS-AN


http://news.aapc.com/index.php/2011/02/understand-payer-guidelines-to-keep-up-to-date-with-anesthesia/

August, 2009 AAPC Coding Edge, Draw a line between Moderate (Conscious) Sedation and Monitored Anesthesia Care

By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN


https://www.aapc.com/blog/25598-draw-a-line-between-moderate-conscious-sedation-and-monitored-anesthesia-care/


November/December 2005 Nancy Maguire's Coding & Billing  Expert

Anesthesia Billing for CRNAs’
 
A timely topic if ever there was  one!  This issue continues to be a source of confusion to physician  offices, billers, hospitals, and insurance companies, too.  A  Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who  is an anesthesia specialist and may administer anesthesia independently or under  physician “medical direction” or “supervision.”  CRNAs’ have been  practicing in the United States since the civil war, and were the first nursing  specialty to be accorded direct reimbursement rights under the Medicare program  when President Ronald Reagan signed the Omnibus Budget Reconciliation Act of  1986 (OBRA), which included direct reimbursement for CRNA’s under Medicare in Section 9320. 
 
Reporting claims for a CRNA with carriers  other than the Medicare program can be confusing, and there are several  different issues for each practice to consider before determining the correct  method.  This article will address considerations such as  employment status, state scope of practice laws, and carrier recognition – as  well as the practical considerations of how to effectively file claims and  calculate separate charges, when necessary.
 
One of the most important aspects to  consider is who employs the CRNA.  A 2003 survey conducted by the  American Association of Nurse Anesthetists (AANA) shows approximately 37 percent  of practicing CRNAs are employed by a physician group, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. In the majority of cases (53%), either the CRNA is employed by a group or is an independent contractor.CRNAs and those who em­ploy them must accept assignment on their claims;  however, filing rules for the various insurance carriers differ. According to the AANA, there are only 36 states that  directly reimburse CRNAs under Medicaid; approximately 38 Blue Shield entities  provide direct reimbursement to CRNAs, and approximately 22 states that mandate  direct private insurance payment to CRNAs.  That leaves a number of  states out of the loop!So let’s try to clear this up…
 
CRNAs may be self-employed and bill for  their own services.  State scope of practice laws determine whether  direction or supervision of a CRNA by a physician is required.In  January, 2004, the American Society of Anesthesiologists (ASA) published a  complete list of state requirements on their web site entitled, “The Scope  of Practice of Nurse Anesthetists.”   Although  several states allow surgeons to supervise a nurse anesthetist – they are billed  as “non-medically directed.”  A surgeon may not wear two hats and collect payment as both the surgeon and the medically directing physician.

When filing claims through the Medicare  program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are  revenue neutral - meaning reimbursement is equal to the same amount.  For example, when medical direction modifiers “QK and QX” are reported  (see table below), reimbursement is divided equally (50% and 50%) between the  physician and the CRNA.When a CRNA is non-medically directed,  full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care  team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems.Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!
 
Many private insurers expect CRNA services  to be billed under the anesthesiologist, on one line of the claim form.  Reporting separately may result in a claim denial or improper payment.  An additional confusion, since many practices generally equally split the  full amount of the bill between the physician and CRNA, is that the claim is  viewed as a duplicate.  Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.   

One way to avoid confusion when you must  bill two claims, i.e. to collect a Medicare secondary balance, is to charge  different amounts for the physician and CRNA.  For example, in our  practice we assigned 70% of the conversion factor to the physician and 30% to  the CRNA;  however, your practice may choose to assign a different value.  Assigning different values when claims must be split  helps identify and separate the services of the physician and the CRNA, as well  as decrease odds the claims will be mistaken as duplicate.It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!

How can you tell when to send separate claims?  One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNA’s.  To receive payment from carriers that require two claims, the CRNA must  have a valid provider number and have reassigned their benefits.  It is important to ensure the provider number is valid before  the CRNA begins working.  Many practices lose revenue by their  inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA  whose number is not yet in place, such as temporary providers.  Although short-term contract or temporary CRNA’s are called “locum  tenens,” the locum tenens modifier is not intended to be used to bill for their  services.  

In most instances, CRNA’s are prohibited  from using the Q6 modifier to receive payment, since by definition the modifier  indicates the service was provided by a “physician.”  However, as to be expected  in the anesthesia world of billing, there are no “absolutes!” Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6  modifier by CRNA’s.Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier. 

When a CRNA is employed by the hospital  and a separate anesthesia group is medically directing, reimbursement is shared  in some cases, and non-existent in others – depending on several factors. First, the method of reporting claims.  As previously  mentioned, not all  carriers recognize split claims or the HCPCS modifiers, and  expect to receive only one bill for anesthesia services.  Unless  the hospital billing department and the anesthesia group have a previous  arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed”
rule to come into play.  In this scenario,  the first claim processed receives payment while the second claim is typically  rejected, ignored, or denied as a “duplicate service.” 
 
The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNA’s.According to the January, 2005 Ohio Job and Family Service Physician Handbook, "Services of a hospital employed CRNA/AA are included in the  facility." In some cases, Medicare offers small hospitals that employ only one  CRNA a "pass through" billing option.  When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B  Carrier for any anesthesia services furnished to patients of that hospital. 
 
It is also important to realize there is a  distinct reimbursement difference between “supervision” and “medical direction.”   While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.Supervision, a claim that is filed with an “AD” modifier, indicates that the  anesthesiologist was either involved with more than four concurrent rooms or  cases (regardless of type of insurance) or failed to meet the medical direction  steps in some states.Medicare penalizes supervised claims by  paying a maximum of four (4) units per case, providing the anesthesiologist was  present for induction.  No time is allowed for any of the  concurrent cases.You may be surprised to learn  that some carriers pay absolutely nothing when an AD modifier is reported.  
 
The AANA estimates that 80 percent of  CRNAs work as partners in a care team environment with anesthesiologists. It is  important that anesthesia billers have a clear understanding of how to bill for  the services of CRNAs in their own state and recognize that not all payers  require two claims.Obtain state guidelines for each major carrier -  Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance  companies are the ones that you agree to in your contract.
 
QZ:   (CRNA modifier – pays 100%)  non-medically directed CRNA services;  CRNA is either working without medical  direction or criteria was not fully met.
  
QX:   (CRNA modifier – pays 50%)  Medically directed CRNA services; the CRNA is being medically directed by an MD,  who has met all required steps for  medical direction. 

QK:   (physician modifier { used in  conjunction with QX modifier}  -pays 50%) Medical direction  of two, three or four concurrent procedures

QY:  (physician modifier { used in  conjunction with QX modifier} -pays 50%) MD is medically  directing one CRNA  

AD:  (physician modifier { used in  conjunction with QX modifier} -pays maximum of four units or  zero) Medical supervision by a physician of more than four concurrent  procedures
 
Q6:(physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”

Source:  HCPCS, 2005
By:  Kelly Dennis, MBA, ACS-AP,  CPC
MGMA E-Connextion, Issue 86, October  2005
Internal audits


Many practices are too busy with day-to-day  work  to keep track of how often they should conduct internal audits. However, if your  practice has a compliance plan, it generally outlines the required audit  frequency. Do you know what your compliance plan requires?

If your anesthesiology practice is using the standard compliance plan outline published by the American Society of  Anesthesiologists in Compliance With Medicare and Other Payor Billing Requirements, your practice is required to review pre-submission (claims reviewed before filing to the insurance carrier) on a quarterly basis, and post-submission (claims reviewed after filing to the insurance carrier) at regular intervals, such as semiannually.

Having anesthesia records available as you start  your internal audit can make an internal audit easier.  If anesthesia records are not available, obtain them from the hospital.
 
An internal audit is simply an objective review of  the anesthesia services billed to monitor the accuracy of claims. It
should be  performed by a qualified employee – such as the office administrator, manager,  certified coder (other than the employee who coded the services), the compliance  officer, a physician, or a combination. Each practice determines the number of  charges or percentage of claims to be reviewed for each provider. It also  determines how to make appropriate corrections and, depending on the internal  audit results, whether to contact legal counsel.   Although the standard compliance plan requires the practice to undertake all claims monitoring with legal counsel, the practice may modify the plan to require legal  counsel consultation only during external audits.  

A simple pre-submission review should compare the  codes and modifiers billed with the documentation on file.  Because  the auditor reviews this information before submitting the claim, corrections  are made during the review process and  corrective actions should be taken and  conveyed to staff.  For example, a review determined the coder  mistook “TKA” for a total knee arthroscopy (01400 base value - 4) rather than  total knee arthroplasty (01402 base value -7).  The practice must take several corrective steps:

1) Change code, if applicable.Different physicians may be using different acronyms;
2) Ensure acronyms in your practice are clearly  defined; and 
3) Request a report of 01400 and 01402 claims filed within the past 18 months to verify accuracy. 
 
Post-submission review is more complex and should  include a review through resolution.  Choose a date within the past  six months, and in addition to checking codes and modifiers used, review payment  processes to ensure correct reimbursement and appropriate adjustments were made.  Each practice should know exactly what payment to expect.  Medicare  pays by location and the amount is standard; other payers may be contracted  using various amount and time calculation techniques so a matrix of expected  reimbursement is helpful.At the very least, a form listing annual  expected amounts is necessary. 

An important area to review is concurrency and documentation of medical direction criteria. Depending on your software concurrency reporting capabilities, it may be necessary to review an entire day of concurrency if your practice includes residents, certified registered nurse anesthetists, anesthesia assistants, or student registered nurse  anesthetists.  It is important to understand that concurrency calculations must include all patients, regardless of
insurance.  While some carriers allow a combination of up to four concurrent cases,  graduate medical rules differ and allow up to two cases when residents or SRNA’s  are involved.

Whether conducting a pre- or post-submission review, keep documentation of all steps taken in a compliance file. Even if your  practice only reviews once a year, make certain the time frame agrees with the  written compliance plan. The adage, “It is better not to have a compliance plan,  than to have one and not follow it,” is particularly true for anesthesia practices, as anesthesia billing rules are often vague and ambiguous.

By Kelly D. Dennis,
kellyddennis@attglobal.net, MGMA  member and president, Perfect Office Solutions, Leesburg, Fla.


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