Coding Confusion Exposes the Complexities of Anesthesia and Healthcare Law

A recent agreement between Emblem Health and the Attorney General of the State of New York emphasizes the costs and complexities of both patient care and healthcare law.

In the agreement, Emblem Health agreed to reimburse patients who were inappropriately charged anesthesia co-payments for colonoscopies that began as preventative procedures but ended with the removal of a polyp or tissue for biopsy. A copy of the agreement is available here.

The Affordable Care Act (ACA) requires health plans to provide full coverage for colorectal cancer screening tests and specified other preventative care with no patient co-insurance, co-payments, or deductible amounts. The agreement states, in part, that “Because colonoscopies necessitate the administration of anesthesia, anesthesia services provided in connection with preventive colonoscopies should likewise be covered without member cost-sharing.” While there had been some plans that provided that first-dollar coverage for the screening procedures, even those included patient cost-sharing provisions for anesthesia services. As a result of the agreement, new code modifiers have been put in place to help alleviate confusion and specify payment.

Going forward, the following code modifiers will be used to further define the procedure, and the patient’s cost-sharing responsibility:

Code 00810: Anesthesia for lower intestinal endoscopic procedures

While this seems a logical and comprehensive solution, its application has proven less so. The instructions provided to Medicare Administrative Contractors (MACs) did not provide information on the -PT modifier. Thus, most MACs have been denying claims for Code 00810 submitted with modifier -PT. Some have also been report to be denying the -33 modifier also, though the reason for that are unclear. The American Society of Anesthesiologists (ASA) is aware of the problem, and has discussed the issue with CMS, whose ASA says “has informed us that they are aware of this problem and are working on [the] best way to address it.”

Tony Mira, President and CEO of Anesthesia Business Consultants, describes two options for anesthesia practices moving forward:

“Pending a resolution of the problem at the CMS level, anesthesia practices have two options for reporting screening colonoscopies that end up with polyp or other tissue removal, neither of them entirely satisfactory.  They can (1) report the -PT modifier on the claim line, which will most likely result in a denial of the claim, which can then be appealed.  When CMS finally straightens out the MACs, the appealed claims should be adjusted.  Alternatively (2) anesthesia providers can file their claims for these services without modifier -PT or -33 and collect the deductible amounts from the patients, as various MACs have instructed, but when CMS does act, it will be necessary to recover the deductibles from Medicare and to refund any amounts received from patients other than the co-payments.  Fortunately for most anesthesia practices, many Medicare patients will likely have met their deductible—$147 in 2015—in connection with other medical and surgical services obtained early in the year, before they receive and are billed for anesthesia for screening colonoscopies.  With the deductibles already satisfied, there will be no need for the anesthesia practice to collect them from the patients whether the MACs accept modifier -PT or not.”

The Removing Barriers to Colorectal Cancer Screenings Act (S. 624, and H.R. 1220) would eliminate cost-sharing under Medicare for preventative screening colonoscopies, regardless of whether or not a polyp was removed. If the legislation passes, there will no longer be a need for CMS to track the -33 and –PT modifiers and follow different payment rules.

The situation is equally confused with regard to private health plans. Though they are not bound by CMS rules barring waivers of deductibles for procedure that become diagnostic or therapeutic, they vary in their use of the -33 modifier for any colonoscopies at all. Some plans apply benefits based on the intent of the procedure regardless of its outcome. Others base the benefits on the outcome, determined by the surgeon. Anesthesiologists should speak directly with their own payers to determine the policy of each.

All of the issues involved in this small detail of anesthesia care focus attention on just how complex anesthesia practice management, let alone legislating healthcare, can be. Patients, clinicians, and healthcare businesses all benefit from clear, logical policies, thorough and accurate recordkeeping, and organizational cooperation. Working with competent, knowledgeable partners will increase efficiency, improve quality, and ultimately raise performance (and profitability) levels for healthcare professionals regardless of their specialty.

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