Anesthesia Coding Alert

Medical research often centers on procedures that include anesthesia (from special types of monitoring to new medications or muscle relaxants), but all care is not automatically billed to the research sponsor. When standard anesthesia care is offered along with services that are part of the research study, a question arises for anesthesia providers: How do you differentiate between services that should be billed to the research sponsor and those that can still be charged to the patient's carrier? Know the Guidelines for Clinical Trial Payment If the physicians you code for participate in research trials, one of the first steps toward correct coding is to learn the national guidelines regarding clinical trials. In the summer of 2000, President Clinton issued an executive memo directing CMS (then HCFA) to "explicitly authorize Medicare payment for routine patient care costs and costs due to medical complications associated with participation in clinical trials." In response, CMS developed the National Coverage Determination (NCD), which outlines the costs associated with clinical trials that Medicare covers.

Clinical trial services that qualify for Medicare coverage include: Qualifying trials The service must be part of a clinical trial that meets criteria CMS has defined. The clinical trial must evaluate an item or service that falls within a Medicare benefit category (such as a physician's service or diagnostic test), have a therapeutic intent, enroll diagnosed beneficiaries rather than healthy volunteers (except when healthy patients are needed as control subjects), and have desirable characteristics (such as being funded by the National Institutes of Health or other national research organizations). Routine costs Some items and services (such as those Medicare usually doesn't cover in other situations) are not included in the clinical trial coverage. But Medicare does cover many other facets of care during the trial, including all items and services that are typically provided even without a clinical trial, services required for clinically appropriate monitoring of the effects of the item or service, and items or services that are medically necessary for the diagnosis or treatment of complications arising during the trial. Determine Who Pays for Which Services Basically, the work involved in a medical trial is divided between treatment that is part of the research trial and other supporting treatment that is medically necessary for the patient. All medically necessary treatments and monitoring during a clinical trial are covered if the condition being treated is usually covered under normal circumstances.

"If you're having a nose job to look better and are enrolled in a study that looks at an improvement in either anesthesia or surgical technique, you would not be covered because the nose job (cosmetic surgery) is a non-covered service by Medicare and most other carriers," explains Scott Groudine, MD, director [...]