Anthem Blue Cross and Blue Shield in Indiana recently announced a payment policy revision that will affect the state’s anesthesiologists. Beginning January 1, 2013, Anthem will no longer calculate the maximum allowable based on the anesthesia conversion factor formula for anesthesia performed during colonoscopies, endoscopies, nerve blocks, and injections.
Instead, anesthesia for these procedures provided in the Indiana service area will be paid at a flat fee: 00740 and 00810 at $200 per case, and 01991 and 01992 at $100 per case.
CIPROMS is helping our clients analyze the financial implications of this change in reimbursement, which can be significant for some groups. In fact, the Anthem allowed amount for 01992 billed with one time unit would essentially be $16.66 per unit, almost $4 below the 2012 Medicare conversion factor allowed amount.
Additionally, claims with modifiers QY, QK, and QX will continue to have the allowed amount reduced by 50 percent.
Some providers have seen this payment policy revision applied beginning in the fall of 2012 without notification. Anthem is reportedly reprocessing those claims for additional payment and has issued notification for the future policy update with 45 day’s notice.
According to the Anthem notice of change, these particularly services were chosen for fixed rate reimbursement because “operative times are predictable and without significant variation.”
In 2006, Anthem indicated that all anesthesia claims for gastrointestinal endoscopic procedures would be subject to medical review and would be allowed only in instances of medical necessity. This decision was based on a 2004 statement published by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy indicating that “In general, diagnostic and uncomplicated therapeutic endoscopy and colonoscopy can be successfully performed with moderate (conscious) sedation.” Anthem has not indicated any change in that policy, and presumably, all 00740 and 00810 billed are still subject to review for medical necessity.
Anthem has suggested that providers with questions or concerns should contact their local Network Relations consultant.
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