Why were anesthesia services chosen as a topic for a comparative billing report (CBR)?
This topic was selected as a CBR due to increased Medicare spending on anesthesia for lower endoscopic procedures. According to the Medicare Fee-for-Service 2015 Improper Payments Report, anesthesia was one of the Top 20 Service Types with Highest Improper Payment Rates. Additionally, the Affordable Care Act (ACA) mandates coverage of colorectal cancer screenings as preventive services. As such, colonoscopy screenings have increased. For more information, select the following link: Medicare Fee-for-Service 2015 Improper Payments Report.
What is the purpose of this CBR?
The Centers for Medicare & Medicaid Services (CMS) utilizes CBRs as tools to educate providers about correct billing procedures. CBR201705 was created to inform providers about their billing and payment patterns for anesthesia services. For this report, we reviewed Fee-for-Service Medicare (Original Medicare) claims with Current Procedural Terminology (CPT®) code 00810. More information about CBRs is available on our website link titled Comparative Billing Reports.
How was it determined which providers would receive CBRs?
To choose recipients for this CBR, we analyzed Medicare Part B anesthesia claims of providers who billed CPT® code 00810 for lower endoscopic procedures. Approximately 8,000 providers were identified as potential CBR recipients due to having different billing practices than their peers. Our search included Medicare Part B claims for colonoscopy services submitted with CPT® codes 45300-45398, G0105, and G0121. Providers who did not receive CBR letters can review a sample on our website at the link, CBR201705 Sample CBR.
Did I receive a CBR because I am billing my claims incorrectly?
Receiving a CBR does not necessarily mean you are billing incorrectly; however, it does indicate that your billing is different than your peers. The CBR is a tool used to compare your billing patterns to the peers in your state and the nation. If you have questions and or concerns about your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Will I be audited since I received a CBR?
The CBR is for informational and educational purposes and is not considered an audit. The CBR team does not perform any audits, nor do we have access to medical charts used for audits. The CBR allows providers to check and see how they compare to their peers; however, if interested in resources that may be helpful with setting up an audit process, please visit our CBR website page at the link titled, Self-Audit Help.
What is the requirement to bill CPT® code 00810?
The CPT® 2016 Professional Edition describes CPT® code 00810 as “anesthesia for lower intestinal endoscopic procedures, endoscope introduce distal to the duodenum.” To be reimbursed for CPT® code 00810, a corresponding colonoscopy procedure must be performed on the same day. The CPT® Manual is available for purchase from the following website: American Medical Association.
What procedure code should providers submit to obtain reimbursement for CPT® code 00810?
CMS has developed two screening Healthcare Common Procedural Coding System (HCPCS) codes for Medicare beneficiaries to use with CPT® code 00810. HCPCS code G0105 indicates colorectal cancer/colonoscopy screenings for high risk individuals. HCPCS code G0121 should be used for colorectal cancer/colonoscopy screenings for those that are not high risk. Otherwise, CPT® code 00810 should be submitted for the same day as a colonoscopy service (CPT® codes 45300-45398). For more information about preventive services, see the following web link: Medicare Claims Processing Manual, Chapter 18, Section 1.2.
Are Medicare patients required to pay a deductible for anesthesia for colonoscopy screenings?
No. Effective January 1, 2015, the Affordable Care Act (ACA) waived the coinsurance and deductible for anesthesia (CPT® code 00810) services performed in conjunction with HCPCS codes G0105 or G0121; however, modifier 33 must be added to the procedure code CPT® 00810 for the waiver to apply. If claims are submitted without modifier 33, MACs will apply the deductible and coinsurance. If the colonoscopy begins as a diagnostic procedure, CPT® code 00810 would be billed without modifier 33 and the co-insurance and deductible would apply. To obtain more information, select the following web links:
- MLN Matters® - Preventive and Screening Services — Update - Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy.
- Affordable Care Act – Section 4104
Will the deductible apply if a polyp is found during the colonoscopy screening?
No. The deductible will not apply. When a growth is found during a procedure, the colonoscopy screening becomes a diagnostic colonoscopy. In this instance, CPT® code 00810 should be submitted with the PT modifier to waive the deductible. For more information, see the following web link, Medicare Claims Manual, Chapter 18, Section 1.2.
Who can provide anesthesia for lower endoscopy procedures?
Anesthesia can be administered by an anesthesiologist or qualified non-physician anesthetist such as a Certified Registered Nurse Anesthetist (CRNA) or anesthesiologist’s assistant. The Medicare Claims Processing Manual states: “Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure.” To see more details, select this link: Medicare Claims Processing Manual Chapter 12 – Section 50-H.
How much will Medicare pay for anesthesia administered for colonoscopy screenings?
According to the CMS website titled Anesthesiologist’s Center, payment for CPT® code 00810 is made according to the Medicare Physician Fee Schedule (MPFS) “based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure is communicated to the A/B MACs by means of the HCPCS file released annually. CMS releases the conversion factor annually.” This information is available at the link, Anesthesiologists Center. Select the following link for more details about the MPFS: Physician Fee Schedule.
How is anesthesia time calculated?
Anesthesia time is reported in minutes on the claim and begins when the provider starts preparing the patient for induction of anesthesia. It does not end until the patient is placed safely under post-operative supervision. According to the Medicare Claims Processing Manual, if an interruption occurs, “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.” Detailed information about anesthesia time is found in the Medicare Claims Processing Manual Chapter 12 – Section 50-G.
What are the guidelines for billing multiple anesthesia procedures?
When more than one procedure is performed under a single anesthesia induction, providers should only bill for one anesthesia service. Per the Medicare Claims Processing Manual, “Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures.” Modifier 51 should be appended to the anesthesia code to indicate multiple procedures. More details are available at the web link: Medicare Claims Processing Manual Chapter 12 – Section 50-E.
What is the anesthesia supervision exemption?
In 2001, CMS established an exemption for CRNAs from the physician supervision requirement. Per CMS, “This exemption recognized a Governor's written request to CMS attesting that he or she is aware of the State's right to an exemption of the requirement and that is in the best interests of the State's citizens to exercise this option.” As of February 2017, the U. S. Territory of Guam and seventeen states have opted out of the physician supervision regulation for CRNAs. The states are: Alaska, California, Colorado, Idaho, Iowa, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin. For more information, select the following web link: Spotlight – Anesthesia Supervision.
For this CBR, we selected Medicare Part B claims with allowed anesthesia services for CPT® code 00810 (lower endoscopic procedures). Providers receiving CBRs were significantly higher than peers in either their state or the nation on at least one of the measures studied. They were also above the 75th percentile in allowed charges ($5,000) and had at least 19 beneficiaries during the period of January 1, 2016 to December 31, 2016.
How are the peers defined?
Providers were identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:
- State: All rendering Medicare providers located in the individual rendering provider’s state, with claims of allowed charges for CPT® code 00810
- National: All rendering Medicare providers in the nation with claims for allowed charges for CPT® code 00810
What do the comparison outcomes mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher is displayed if the provider’s value is higher than the peer value and the statistical test used confirms significance.
- Higher is displayed if the provider’s value is higher than the peer value, but the statistical test does not confirm significance.
- Does Not Exceed is displayed if the provider’s value is not higher than the peer value.
- N/A (Not applicable) is displayed if the provider does not have sufficient data for comparison.
How was the data obtained for this report?
Claims with CPT® code 00810 were first pulled from the Integrated Data Repository (IDR) on April 13, 2017 for Medicare Part B providers who were identified by Rendering NPI. The claim lines used in this analysis cover dates of service between January 1, 2016 and December 31, 2016. For more information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).
What does Table 1 show?
Table 1 is titled Modifiers Frequently Used with Anesthesia Services. The first column lists the Modifier and the second column lists a Description of each modifier. If you would like to see the definitions of these modifiers, please select the following link: CBR201705 Sample CBR.
What is the meaning of Table 2?
Table 2 is titled Summary of Your Utilization of CPT® Code 00810. This Table shows the CPT® Code, Allowed Charges, Allowed Services, Visit Count and Beneficiary Count for dates of service from January 1, 2016 through December 31, 2016. A provider’s percentages and averages, denoted in Tables 3 through 5, are calculated from the utilization of the procedure code in Table 2.
What is the significance of Table 3?
Table 3 is the provider’s Average Time Units Appended per Visits. The purpose of this measure is to compare individual provider’s time units appended to the anesthesia code to his/her peers. Our sample CBR shows that the mock provider had an average of 2.56 time units, which was Higher than the state’s average of 2.50 and Significantly Higher than the national average of 2.27. To view the percentages for each state and the nation, select the following link: CBR201705 Statistical Debriefing.
How are the mock provider’s average time units calculated in Table 3?
The average was calculated as the Total Time Units (212.3) divided by the Total Number of Visits (83), for an average of 2.56 time units. To view the mock provider’s example, select the following link: CBR201705 Sample CBR.
What is the explanation for Table 4?
Table 4 is an example of the provider’s Percentage of Visits without an Allowed Colonoscopy Claim. This measure was included in this CBR because anesthesia CPT® code 00810 should accompany an allowed colonoscopy service. Colonoscopy services with CPT® codes 45300-45398, G0105, and G0121 were considered for this measure. This mock provider’s percentage is one (1) percent, which Does Not Exceed the state’s seven (7) percent or the nation’s four (4) percent. To see the percentages for each state and the nation, please visit the CBR website at CBR201705 Statistical Debriefing.
How is the mock provider’s percentage of visits without an allowed colonoscopy calculated in Table 4?
The percentage is calculated as the Number of Visits without Colonoscopy (1) divided by the Total Number of Visits (83), and then multiplied by 100. This results in approximately one (1) percent for the provider. This mock provider’s example can be viewed at the following link: CBR201705 Sample CBR.
What is the meaning of Table 5?
Table 5 is an example of the provider’s Percentage of Visits Appended with Modifier AA. Anesthesia codes appended with modifier AA signify that the procedure is personally performed by a physician, resulting in higher allowed charges, when combined with the time factor. Our sample CBR shows that out of a total of 83 visits, the mock provider has a total of 76 anesthesia visits appended with modifier AA making up 92 percent of his/her visits. Since the state’s percentage is 27 percent and the nation’s is 47 percent, this mock provider is Significantly Higher than the state and national rates. To view results for each state and the nation, select the following link: CBR201705 Statistical Debriefing.
How is the mock provider’s percentage in Table 5 calculated?
This percentage is calculated as the Number of Visits with Modifier AA (76) divided by the Total Number of Visits (83), and then multiplied by 100, resulting in approximately 92 percent. To see this mock provider’s example, select this link: CBR201705 Sample CBR.