Inappropriate Billing of Anesthesia for Spinal Pain Management Procedures

🎥 Watch our short video breaking down the OIG’s findings on inappropriate anesthesia billing. Then, keep reading for the full article below.

Inappropriate Billing of Anesthesia for Spinal Pain Management Procedures

The Department of Health and Human Services Office of Inspector General (HHS-OIG) recently published an audit that concluded, “Medicare Could Have Saved an Estimated $17.7 Million if CMS’s Oversight Had Prevented At-Risk Payments for Anesthesia Administered During Spinal Pain Management Procedures”. At the center of HHS-OIG’s audit is a billing scheme, wherein anesthesia codes for moderate sedation, general anesthesia, or monitored anesthesia care are billed for the same patient on the same date of service as a spinal pain management (SPM) procedure, such as joint injections or denervation procedures. It is unusual for SPM procedures to require the use of such anesthesia, and therefore, providers who administer moderate sedation, general anesthesia, or monitored anesthesia care that correspond to SPM procedures should be scrutinized. HHS-OIG estimated that moderate sedation or monitored anesthesia care is necessary for approximately 5% of facet-joint injections, epidural steroid injections, and sacroiliac injections, and approximately 20% of facet-joint denervation procedures.

💡HHS-OIG’s report advised that general anesthesia would be expected to be administered only 0.01% of the time for SPM procedures.

Access the HHs-OIG Report Here

What Do the Medicare Administrative Contractors Say?

Local Coverage Determination (LCD) guidance shows that Medicare Administrative Contractors consistently indicate that moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) are typically considered unnecessary, not reasonable, and therefore not reimbursable for SPM procedures. Key points by contractor are outlined below:

💡In summary, sedation for SPM procedures is not routinely covered by any Medicare contractor and only permitted in rare, exceptional cases with clear documentation of medical necessity.

❓How does your plan’s payment policies compare?

Is This on Your Radar??

If this isn’t already on your radar, we recommend that payers:

  • Data mine for providers who are billing for moderate sedation, monitored anesthesia care, or general anesthesia for SPM procedures for a significant percentage of SPM encounters. See related CPT codes below.

  • Consider implementing a pre-payment review process for anesthesia claims billed with SPM procedures.

  • Implement coverage policies that are similar to existing LCDs if your plan does not follow Medicare guidelines.

💡Keep in mind that providers may bill the anesthesia under a separate Tax identification Number from the SPM procedure.

Related CPT Codes

HHS-OIG’s report listed the following CPT codes associated with the inappropriate billing scheme:

💡Create proactive claims queries that capture any combination of the SPM procedure and anesthesia CPT codes for the same member and same date of service.

Real - World Findings

While this is certainly not a new scheme, we continue to find inappropriate payments being made for claims including moderate sedation, general anesthesia, and/or monitored anesthesia care with SPM procedures across government and commercial health plans.

  • One of our clients had paid a single provider over $3 million for anesthesia procedures for the same patient on the same date of services as an SPM procedure!

  • Another Integrity Advantage client has taken a proactive approach by placing providers who engage in this billing pattern on pre-pay review. 😊

In summary, if you haven’t already done some digging - take a look at your data to see if this scheme is impacting your organization. Also, consider taking a look at your payment policies to ensure you are catching improper billing before it becomes a bigger problem. This is just another example of how you can showcase the value of your FWA program!

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With more than 30 years of experience supporting payers, the team at Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).

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Evie Mazzoccone