Anesthesiology practices are particularly vulnerable to Medicare audits because of the unique complexities of the billing process when it comes to time calculation, coding, and other areas. The federal government’s Recovery Audit Contractors (RAC) program fully understands this vulnerability and is making the most of it, with aggressive audits to recoup any money that the government deems was issued inappropriately.
The federal government has instituted the RAC program by contracting with non-governmental firms to provide audits, setting up an incentive plan whereby the auditors only get paid when they identify billing mistakes within a practice and recoup Medicare overpayments.
This sets the stage for a very aggressive auditing approach, with the federal False Claims Act setting penalties as high as $11,000 per claim, plus three times the claim amount, plus legal fees. Because the Tax Relief and Health Care Act of 2006 made the RAC program permanent, these aggressive audits will only continue over the coming years.
Common Audit Problems
A summary of the billing areas that are commonly cited as problems is included below. These billing areas are frequent stumbling blocks to ensuring an anesthesiology practice is reimbursed fully and appropriately for its work.
Accurate Coding and Documentation are Vital
Good communication between the anesthesiologist and the billing staff is the key to proper anesthesia coding and billing. It all comes down to accurate and thorough documentation. Inaccurate or inadequately documented anesthesia records lead to inaccurate (false) claims. Providing complete and accurate information to the billing staff promotes compliance and accelerates the billing and collection process. Inconsistencies in the anesthesia record are potentially false claims. For example:
- Documentation showing the same physician in two places at one time
- CRNA with overlapping case times
- Services marked on a billing slip but no accompanying documentation in the anesthesia record
Invasive monitoring devices
Placement of arterial, central venous and pulmonary artery catheters and TEE are not included in the base units. However, Medicare does include routine monitoring on TEE on heart cases in the base units.
Billing for personally performed services
Under Medicare regulations, an anesthesia procedure is considered “personally performed” by the anesthesiologist if the physician is continuously involved in a single case. When billing for personally performed physician services (AA modifier), the physician may not leave the operating room to perform other medical procedures.
The anesthesiologist must remain physically present in the operating room during the entire procedure. If the anesthesiologist is not continuously involved with the case, then it is not considered a personally performed service and should be reported using the medical direction modifiers.
Modifiers are two-digit indicators used to modify payment of a procedure code, assist in determining appropriate coverage, or identify the detail on the claim. Every anesthesia procedure billed to all carriers must include one of the following anesthesia modifiers:
|Anesthesia services personally performed by the anesthesiologist
|Medical direction of one CRNA by an anesthesiologist
|Medical direction of 2, 3 or 4 concurrent anesthesia procedures
|Supervision, more than four procedures