By: Hal Nelson, CANPC
MSN Vice President of Anesthesia Services
One of the best pieces of advice I’ve given to anesthesia practices over the years has been simple; review the surgical description you’ve charted at the end of each case to ensure that nothing needs to be amended. There are many examples of how not doing so can result in lost revenue and/or delayed claims submission, but in this article, we’ll focus on anesthesia for Screening Colonoscopies.
To understand why this is important, we must first look at how Medicare pays for Screening Colonoscopies. CMS (which governs Medicare and Medicaid) uses alternate anesthesia base unit values for screening colonoscopies and seven other ASA codes. So, instead of allowing 4 base units for screening code 00812 as the ASA Relative Value Guide suggests, CMS only allows 3. This is also true for your managed care contracts that align with CMS (and not ASA) base unit values, so check your contract language for this subtle (yet important) distinction.
A Medicare anesthetic charted as ‘Screening Colonoscopy’ will yield a total of around 5 units (3 base and 2 time units). Using a conversion factor of roughly $20, that’s a $100 allowable for your anesthesia service. If you take that same exact anesthetic where charting captures the removal of polyps, the case is valued at 4 base units and your allowable is 20% higher. While this may not seem significant now, it will definitely add up over time.
From a coding perspective, Medicare wants true Screening Colonoscopy anesthetics reported as code 00812. However, when a polyp is removed, instructions state to report the service as code 00811-PT. The -PT modifier is informational only, as it tells Medicare that the case began as a screening and was converted to a diagnostic/therapeutic procedure. The real significance here is that code 00811 is valued at 4 base units, as opposed to the 3 base units tied to screening code 00812.
If your practice performs GI anesthesia and all of your providers are cognizant of this charting requirement, I’d be pleasantly surprised. Unfortunately, most clinicians are unaware of this billing rule and are underpaid by 20% on all Medicare Polypectomies.
So, what can you do to analyze your practice and billing company in this area? Provider educational sessions are highly recommended, but I believe that you need data to identify outlier clinicians whose charting appears suspect.
To do so, we’ll need a baseline to compare to that speaks to the average number of lower GI screenings which are converted to Polypectomies. A recent study in the Gastroenterology Journal shares their findings in this regard. They looked at more than 46,000 patients undergoing a Screening Colonoscopy and found that 27% had polyps both identified and excised, in their control group.
Upon doing my own analysis of 13 independent anesthesia practices who perform anesthesia for GI endoscopy, I found this number to be consistent with my findings. Eight of these practices fell in the 22%+ range, while six outlier groups had values of 14.5% and below. The latter groups (those highlighted in blue in the chart) were flagged for immediate educational outreach, since their anomalous values merited further review.
In summary, if you perform GI anesthesia, this is something that you and your biller should be monitoring, by location and provider. It’s an easy way to see if your practice is leaving money on the table.
Hal has 30+ years of experience on both the payor and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.
