Anesthesia Coding Alert

Proposed rule for MPFS 2021 also continues some changes due to COVID-19.

August 3 brought the introduction of the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (PFS) proposed rule from CMS – and there were quite a few surprises within the 1,350+ pages, including sizeable cuts to both the national and anesthesia conversion factors.

Conversion Factors See Significant Shifts

First things first: The bottom lines for most physician practices will take a hit, thanks to CMS aiming to cut the conversion factor (CF) by 10.61 percent. According to the proposed rule, Section 101(a) of MACRA changed the way the CF is calculated; plus, the office/ outpatient E/M payment rate changes influenced the agency’s decision to lower the CF.

“With the budget neutrality adjustment to account for changes in [relative value units] RVUs, as required by law, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09,” CMS indicates.

Remember: The national CF is what you use when calculating payment when your providers perform surgical services such as postoperative pain management blocks, invasive line placements, emergency intubations, TEEs, etc., reminds Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Public outcry: As expected, industry organizations are rattled by the major CF dip, especially in the midst of COVID-19 spikes. Backing up cash-strapped providers, the American Medical Association (AMA) urged Congress to get involved before the final rule is released later this year.

“The AMA appreciates that CMS will implement significant increases to the payment for office visits, based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC),” acknowledged AMA President Susan R. Bailey, MD, in a statement. “Unfortunately, these office visit payment increases, and a multitude of other new CMS proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11 percent to the Medicare conversion factor.”

Bailey added, “For this reason, the AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases. Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time.”

Anesthesia factor: The news isn’t much better for anesthesia providers who are paid according to the anesthesia conversion factor (ACF) instead of the national CF. According to the American Society of Anesthesiologists (ASA), the proposed 2021 national ACF is set for $19.96, which is a substantial drop from the current ACF of $22.20.

The actual conversion factor you use — either NCF or ACF — will depend on your geographic location. The amounts here, however, give you a good ballpark for what to expect.

CMS offers a breakdown of the expected impacts from the payment rate change by specialty in the proposed rule. The details are in Table 90; however, annual changes, volume of patients, and services offered will also greatly affect Medicare revenues, says Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in a blog post.

Supervision Updates Are Extended

CMS adopted an interim final policy for the duration of the public health emergency (PHE) related to the COVID-19 pandemic that revised the definition of “direct supervision;” the new definition included virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications (85 FR 19245). The update was made because CMS realized that, in some cases, the physical proximity of the provider might increase infection exposure risk to the patient and/or provider.

Update: The CY 2021 MPFS proposed rule allows direct supervision to be provided using real-time, interactive audio/video technology through Dec. 31, 2021 (excluding telephone calls that do not also include video).

The proposed rule also includes interim policy changes for supervision services of teaching physicians: Teaching physicians may use audio/video real-time communications technology to interact with a resident through virtual means, to meet the requirement of being present for the key portion of the service.

However: This virtual supervision allowance might not apply to anesthesia cases. An excerpt of the proposed rule reads:

“While flexibility to provide direct supervision through audio/video real-time communications technology was adopted to be responsive to critical needs during the PHE to ensure beneficiary access to care, reduce exposure risk and to increase the capacity of practitioners and physicians to respond to COVID-19, we are concerned that direct supervision through virtual presence may not be sufficient to support PFS payment on a permanent basis, beyond the PHE, due to issues of patient safety. In complex, high-risk, surgical, interventional, or endoscopic procedures, or anesthesia procedures, a patient’s clinical status can quickly change. To permit payment under the PFS for these teaching physician services, we believe the services must be furnished with a certain level of personal oversight and involvement of the teaching physician who has the experience and judgment that is necessary for rapid on-site decision-making during these procedures.”

The ASA and other groups await more clarification on how this update to the MPFS may — or may not — change teaching physician practices for anesthesiologists during the PHE.

“I’ve had some questions about reduced personnel during the pandemic and whether the rules would be affected,” Dennis says. “While it is hard for me to know what the government would think, I think the patient is supposed to be first priority in an emergency situation.”

Supplemental information: According to documents from CMS regarding waivers in response to COVID-19:

• Physician Services. CMS is waiving requirements under 42 CFR §482.12(c)(1)–(2) and §482.12(c) (4), which requires that Medicare patients be under the care of a physician. This waiver may be implemented so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. This allows hospitals to use other practitioners to the fullest extent possible.
• Anesthesia Services. CMS is waiving requirements under 42 CFR §482.52(a)(5), §485.639(c) (2), and §416.42 (b)(2) that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician in paragraphs §482.52(a)(5) and §485.639(c)(2). CRNA supervision will be at the discretion of the hospital and state law. This waiver applies to hospitals, CAHs, and ambulatory surgical centers (ASCs). These waivers will allow CRNAs to function to the fullest extent of their licensure, and may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.

Deadline: The proposed rule was published in the Federal Register on Aug. 17.  CMS will take comments on it until 5 p.m. on Oct. 5, 2020. You can review the proposals at https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-17127.pdf.