Anesthesia Coding Alert

Its a typical day in the billing/coding area of a busy anesthesia practice, and the conversation is pretty typical, too. I know we have to use RVUs to get reimbursed. They tell carriers how complicated a procedure is and, basically, how much to pay. But these RVUs can be a coding nightmare: ASA and HCFA give different values to the same codes. If we consistently bill with either ASA or HCFA codes we could lose money. If we keep switching between the two, it gets confusing and time-consuming. And local carriers? Thats another story! How did all this start anyway? Why are there so
many discrepancies?

Understand the Story, Then Code Wisely

HCFA adopted ASAs Relative Value Guide in 1988 as a way to designate a procedures value. But, theres a hitch. ASA publishes RVU changes annually, yet HCFA has not updated its version of sanctioned RVUs since 1992. And, though HCFA might accept new anesthesia CPT code each year, it negotiates with ASA and the AMA before deciding which RVUs to use with the new codes. Thats the crux of the coders dilemma.

These RVU discrepancies, evident in many established codes, are cropping up in new codes as well. For example, the new anesthesia code, 00537 (anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation), has an ASA base value of 10; HCFA lists it as 7. And 00635 (anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture) has an ASA value of 5, but a HCFA value of 4.

However, the value differences dont always favor using ASA codes. HCFA has a higher base value for code 01215 (anesthesia for open procedures involving hip joint; revision of total hip arthroplasty), with 10 RVUs as opposed to 8 from ASA. Code 01112 (anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest) also has a higher HCFA base value (5) than ASA (4).

To make matters even more confusing, some of HCFAs existing RVUs for procedures might decrease from one year to the next, because HCFAs goal is to keep the Medicare budget neutral. So, it decreases some procedures base units to help meet the overall demand of new codes that need RVUs.

Look at More than Money Before Choosing RVUs

Knowing which RVU system to follow can be simple, says Devona Slater, CMCP, president of Auditing for Compliance and Education Inc., a consulting firm in Leawood, Kan., that focuses on physician compliance plans in anesthesia and pain management. We do several things to simplify the process. We bill all carriers with ASA units, participate with Medicare, and have a contractual file that is individually loaded by carrier to note differences in the procedure RVUs. Our staff rarely has a problem keeping up with the differences when they compare receipts with the computerized file.

Theresa Ruiz-Law, director of managed care and reimbursement for the American Association of Nurse Anesthetists in Park Ridge, Ill., says a practices payer mix might help determine which RVU system would bring better reimbursement and be easier to work with. If I have predominantly Medicare or Medicaid patients whose carriers have told me to use HCFAs RVUs, then Id set up a fee schedule in my billing system to reflect Medicares RVU rates, she says. Otherwise, Id set the fees based on ASAs RVUs for the private payers and see what they reimburse.

Then again, some providers always bill with ASA units unless the HCFA units for the same procedure are higher. Whichever units you start with, Slater and Ruiz-Law say the end result should be the same get reimbursed. We always charge the same amount for the procedure and adjust it on the back end, Slater says.

You cant have several fee schedules or units in place for each payer, unless your billing system can handle it, Ruiz-Law agrees. Those limitations mean you would usually charge one flat rate and adjust or write off the portion of the fee that was not reimbursed.

For example, an anesthesiologist participates in a patients cataract surgery (00142, anesthesia for procedures on eye; lens surgery). ASA allows 6 RVUs for the procedure, and HCFA allows 4. If the claim is filed with 6 RVUs and the carrier allows only 4, the provider will write off the uncollected amount. Filing with the higher amount simplifies the initial billing process, and might pay off in the long run.

Keep Abreast of Carrier Requirements

Some coders say they see more discrepancies between ASA and HCFA RVUs each year. That might be true, but remember that the ASA and HCFA codes and RVUs are guidelines not rules so not all carriers accept them. Taking some simple steps, such as negotiating RVUs for procedure criteria with your local carriers, can ensure that you agree on charges and reimbursement. Medicare might want you to use HCFAs RVUs, but almost all other carriers use ASA, Slater says. We actually purchase extra
copies of the ASA RVU books each year and give them to the carriers with whom we negotiate so were all on the same page.