Having trouble getting your anesthesia claims for screening colonoscopies paid? Two recent directives by the Centers for Medicare and Medicaid Services (CMS) should help.
Anesthesia for Colonoscopies Covered with No Cost Sharing under the ACA
If anesthesia is “medically appropriate” during a screening colonoscopy, payers are required to cover the cost of the anesthesia through their preventative plan coverage with no cost sharing passed on to patients. That was the guidance issued last week from CMS clarifying several key factors in the implementation of the Patient Protection and Affordable Care Act.
This is good news both for consumers who have been surprised by out-of-pocket costs on covered preventative services and for anesthesiologists who perform the services and often have to fight to receive payment.
While this new guidance related to anesthesia coverage will take effect immediately, no one is sure whether payers will go back and pay for past anesthesia services during screening colonoscopies.
“Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years,” said Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable. They spoke to Kaiser Health News for its coverage of the CMS guidance.
Medicare Guidelines for Billing Anesthesia during Colonoscopy
While the CY 2015 Medicare Physician Fee Schedule Final Rule finalized CMS’ proposal to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies, more guidance was needed to ensure that beneficiary coinsurance and deductible would not apply to those anesthesia services. As well, the PFS policy indicated that screening colonoscopies converted to diagnostic tests or other procedures would also have the deductible waived, though coinsurance would apply.
The April directive by CMS reiterated that for dates of service on or after January 1, 2015, physicians submitting claims to Medicare should use modifier -33 on HCPCS 00810 for colonoscopies “when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect.” As well, the transmittal indicated that modifier -PT should be used when a colorectal cancer screening test is converted to a diagnostic test or other procedure.
CMS instructed Medicare Administrative Contractors (MACs) to not apply the deductible and coinsurance to claim lines for HCPCS 00810 services when billed with modifier -33 and to not apply the deductible when HCPCS anesthesia code 00810 is submitted with the -PT modifier per the PFS Final Rule.
Palmetto GBA, the Railroad Medicare MAC, has announced that they will automatically reprocess all denied claims. However, not all MACs have indicated they will be automatically reprocessing.
What Should You Do?
1. Talk with your billing department or billing company to assess how this issue has affected your practice.
2. Contact your MAC and other payers to see what actions they may be taking to review and pay previously denied claims.
3. If your MAC or other payers are not taking action on their own, consider appealing all denials and improperly adjudicated claims.
For more information about billing for anesthesia during screening colonoscopies, review the following documents for more information about the recent directives:
- MLN Matters® Number: MM8874 Revised
- FAQs about Affordable Care Act Implementation Part XXVI
- Transmittal 3232: Preventive and Screening Services — Update – Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy
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