Anesthesiologists don't exploit insurance rules by "upcoding" patients' medical status in order to receive higher reimbursements for surgical anesthesia, suggests a study in Anesthesia & Analgesia.
Using a national anesthesia database, Dr. Robert Schonberger of Yale School of Medicine and colleagues analyzed trends in health status coding for patients younger than 65 versus 65 and older. Most private insurance plans provide additional reimbursement for providing anesthesia to patients with more severe medical problems, based on the widely used American Society of Anesthesiologists (ASA) Physical Status score.
No 'Discontinuity' in Coding from Before to After Age 65
That means anesthesiologists are paid more for managing patients in worse health, typically coded as an ASA score 3 to 5; compared to those with no or only mild health problems, with an ASA score of 1 or 2. But the situation changes after patients become eligible for Medicare at age 65. Medicare reimbursement for surgical anesthesia is the same, regardless of the patient's health status.
Dr. Schonberger and colleagues wanted to see if this change in reimbursement was reflected in an age-related "discontinuity" in reported ASA Physical Status scores. In other words, would anesthesiologists be more likely to report worse health status in patients under age 65, when there's a financial incentive to do so; compared to age 65 or older, when that incentive is removed?
To answer that question, the researchers analyzed data on nearly 50,000 patients undergoing anesthesia for surgery to repair hip or leg bone fractures. These procedures were chosen because they are "nondeferrable" -- they can't be delayed to take advantage of Medicare eligibility, as some patients will do for less-urgent procedures such as cataract surgery.
The results showed "no evidence for a significant discontinuity" in ASA Physical Status scores from before to after the age of Medicare eligibility. In multiple analyses, patient age older versus younger than 65 was not a statistically significant predictor of reported ASA scores.
"This finding is consistent with the conclusion that...there is no widespread upcoding of ASA Physical Status scores that ceases at age 65 in association with changes in payer incentives," Dr. Schonberger and coauthors write. They calculated that their model would be able to detect "deliberate upcoding" if it occurred in more than two percent of patients.
The results are reassuring, because they "do not support the presence of fraudulent ASA Physical Status scoring" in response to payment incentives. A previous study of Medicare-covered general outpatient office visits identified billing patterns consistent with "deliberate upcoding -- possibly in pursuit of higher reimbursements." Other studies have found evidence of "code creep" for services that are reimbursed according to care intensity.
"This study shows how anesthesiologists are proactively gathering data to ensure that we are providing payors with accurate data," comments Dr. Steven L. Shafer of Stanford University, Editor-in-Chief of Anesthesia & Analgesia. "We are also putting in places the structures and analysis to ensure that as a practice we are following the rules."
While the study doesn't have the sensitivity to detect individual cases, Dr. Shafer notes, "It does show that overall we are correctly billing for our services, and not gaming the system with 'upcoding' to inappropriately increase reimbursement."
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