MLN Announced: Medicare paid over $92 million in incentives for 2008 under the Physician Quality Reporting Initiative (PQRI)

Incentive Payments for Meaningful Use of EHR Technology Does NOT Apply to Anesthesiologists
 
The American Recovery and Reinvestment Act establishes an incentive program that provides incentive payments to eligible physicians (EP) and eligible hospitals for meaningfully using electronic health records (EHR).  While many specialists are learning the conditions under which they can capitalize on these incentive payments, anesthesiologists will learn that they do not qualify as EPs, thus not able to receive incentive payments for their meaningful use of EHRs.
 
One requirement that a physician satisfy is that s/he is a non-hospital-based physician.  “Hospital-based” physicians are defined to include those that provide 90% of their Medicare-covered services within a Place of Service (POS) of 21, 22, or 23—either an inpatient hospital, outpatient hospital, or emergency room hospital, respectively.  Furthermore, the statute explicitly states that anesthesiologists—who furnish substantially all of their Medicare-covered  services in a hospital setting, using the hospital’s facilities and equipment, and qualified EHRs—are not eligible to receive the incentive payments because they are not bringing their own equipment to the hospital in furtherance of the medical services they perform.  If a hospital demonstrates is meaningful use of an EHR, it can qualify for incentive payments.

CMS Issued Final Regulations Regarding Payment for Anesthesia Services and Teaching CRNAs.

CMS Issued Final Revisions to Hospital Interpretive Guidelines Pertaining to Anesthesia.

CMS 2010 Proposed Physician Fee Schedule – Anesthesia Update!

Last week, the Centers for Medicare and Medicaid Services (CMS) released the 2010 Proposed Physician Fee Schedule (PPFS).  CMS stated it will allow comments to be submitted until August 31, 2009 prior to making its final fee schedule, which is to be released in November.    

New Payment Rates

The new payment rates go into effect January 1, 2010.  The proposed rule cuts Medicare spending on physician services by 21.5%.  Anesthesiologists who once experienced a $20.92 national average conversion factor will now experience a $16.42 national average conversion factor, if the propositions are adopted. 

Anesthesiology Teaching Rule (Page 396)

If the proposal goes into effect as written, beginning January 1, 2010, the rules for teaching anesthesiologists will be similar to the current criteria for teaching surgeons. 

If an anesthesiologist is involved in furnishing anesthesia services to a patient, the services can be furnished in one of three scenarios.  The anesthesiologist may

           1.       Personally perform the anesthesia services alone;

           2.       Be involved in the case as a teaching anesthesiologist with an anesthesia resident; or

           3.       Provide medical direction for two, three, or four concurrent cases involving a qualified individual (i.e. CRNA, AA, anesthesia resident, student nurse anesthetist).

If the physician personally performs the service or acts as a teaching anesthesiologist with a resident, payment would be the regular fee schedule rate.  If, however, the physician is providing medical direction, the payment would be at 50% of the applicable fee schedule amount.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires a “special payment rule for teaching anesthesiologists.”  This provision will allow physicians to receive payment at the regular fee schedule rate for the teaching anesthesiologist involved in training residents in either one or two concurrent anesthesia cases involving residents as long as certain criteria are met (Page 398). 

The payment rule applies to teaching anesthesiologists for the single resident case or two concurrent cases both involving anesthesia residents, as long as the teaching anesthesiologist meets certain requirements (§§ 1848(6)(A) and (B) of the Act).  The statute, however,  does not address a single resident case that is concurrent to another involving a CRNA, AA, or another qualified individual who may be medically directed.  In the proposed rule (Page 397), CMS has determined that in a mixed concurrent case scenario (e.g., one resident case and one CRNA case going on concurrently), CMS will pay the unreduced fee schedule rate for the teaching resident case and the medically directed rate for the CRNA case.  In the medically directed CRNA room, the CRNA and the anesthesiologist will each be permitted to bill 50% if the medical direction requirements are met.   

An issue also arises as to the effect on a teaching case if the anesthesiologist is involved in more than one additional medically directed case.  According to the Accreditation Council on Graduate Medical Education (ACGME), for approved anesthesia residency programs, a faculty supervisor may not direct anesthesia at more than two anesthetizing locations in the clinical setting.  In the instance that a faculty supervisor is providing services in two concurrent cases, the teaching anesthesiologist may be engaged in two concurrent cases, two concurrent anesthesia resident cases, or in two mixed concurrent cases—one a resident case and the other a CRNA or AA case.  In the proposed rule, CMS clarifies this issue  so that in order for the anesthesiologist to receive 100% payment for the teaching resident case, the teaching case must be the only case or must be concurrent to only one other case  that is being medically directed by the anesthesiologist. 

In the proposed regulations, CMS also takes a strict position on hand-offs of cases between anesthesiologists (Page 402).  The proposed regulation requires that the same individual teaching anesthesiologist be present during all of the key or critical parts of the case and can only hand-off to another teaching anesthesiologist with whom the teaching anesthesiologist has an arrangement and who is immediately available to furnish services during non-critical or non-key portions.  This provision is likely to create concerns with some anesthesia groups as it may not reflect the reality of how the services are actually delivered.   CMS specifically seeks comments on this controversial issue. 

Teaching CRNAs (Page 406)

The proposed rule also addresses teaching CRNAs.   So long as a teaching anesthesiologist is not medically directing a teaching CRNA (in which case the teaching anesthesiologist and the teaching CRNA would each receive 50% of the fee scheduled amount), the teaching CRNAs supervising nurses in two concurrent cases will not experience a reduced fee schedule rate for each case.  If this proposed change is adopted, then the current face-to-face limitation will be abolished.   By way of clarification, the proposed rule provides that a teaching CRNA involved in two concurrent student CRNA cases will be entitled to receive 100% for each case.    Moreover, in a case where an anesthesiologist is medically directing a CRNA, who in turn is acting as a teacher to a student CRNA, the anesthesiologist and CRNA will continue to receive 50% of the regular fee schedule amount.