Medicare: Nurse Anesthetists Billed for Few Chronic Pain Procedures; Implementation of CMS Payment Policy Inconsistent
Released: 2014-03-10T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Chronic pain costs the nation about $600 billion each year, a quarter of which is borne by Medicare. One MAC, Noridian Healthcare Solutions (Noridian), began denying CRNA claims for certain chronic pain services in 2011, citing patient safety concerns. CMS issued a rule, effective January 2013, clarifying that CRNAs can bill Medicare for “any services that a [CRNA] is legally authorized to perform in the state in which the services are furnished,” including chronic pain management services. GAO was asked to review Medicare's payment policy regarding the provision of chronic pain management services by CRNAs. This report examines, among other things, (1) trends in Medicare provider billing for selected chronic pain procedures; (2) in which states MACs allowed payment for selected procedures billed by CRNAs as of early 2013; and (3) how MACs implemented the payment policy. To do this, GAO selected seven categories of chronic pain procedures, in consultation with pain care experts. GAO analyzed Medicare claims data from 2009 through 2012, by provider type and geography. To determine which MACs allow CRNA payments and how MACs implemented CMS's policy, GAO interviewed medical directors at all nine MACs.

section_title: What GAO Found
paragraphs: From 2009 through 2012, certified registered nurse anesthetists (CRNA)—a type of advanced-practice nurse specializing in anesthesia care—billed Medicare fee-for-service (FFS) for a minimal share of selected chronic pain procedures, less than ½ of 1 percent of these procedures in each year. Physicians without board certification in pain medicine billed for the majority of selected procedures each year, while pain physicians consistently billed for roughly 40 percent of selected procedures. Furthermore, although the number of chronic pain procedures billed by all rural providers increased from 2009 through 2012, the number of procedures billed by rural CRNAs declined over the period. Of all CRNA claims for selected procedures, the share billed by CRNAs in rural areas fell from 66 percent in 2009 to 39 percent in 2012.

As of early 2013, Medicare Administrative Contractors (MAC)—entities that pay medical claims on behalf of Medicare—allowed payment to CRNAs for all selected procedures in 19 states, allowed payment for a subset of selected procedures in 30 states and the District of Columbia, and denied payments for all selected procedures in 1 state. Where MACs allowed payment to CRNAs for only certain procedures, payment policies indicated substantial variation in the specific allowed procedures.

Three of the nine MACs took steps to implement a Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) rule, effective January 2013, that defers to state scope of practice laws to inform coverage for CRNAs. CMS relies on MACs to review each state's CRNA scope of practice laws. However, most MACs reported difficulty interpreting state scope of practice laws regarding the services that CRNAs are allowed to provide; MACs noted that state scope of practice laws generally lack detail on which specific services CRNAs can perform. In addition, two MACs assumed that Medicare's rule requiring physician supervision for anesthesia services provided by CRNAs in hospital and ambulatory surgical center settings applied to chronic pain management services provided in all settings; this may have unnecessarily restricted the services for which CRNAs are allowed to bill in certain states.

section_title: What GAO Recommends
paragraphs: GAO recommends that CMS provide specific instructions to MACs on (1) how to determine coverage with reference to a state's scope of practice laws, and (2) the application of the CRNA supervision rule. HHS concurred with these recommendations.

section_title: Letter
paragraphs: More than 100 million Americans suffer from chronic pain, costing the  nation roughly $600 billion each year, a quarter of which is borne by the  Medicare program, according to the Institute of Medicine (IOM). Unlike  acute pain—which typically has a sudden onset and is expected to last a  short time in conjunction with a specific injury or illness—chronic pain  lasts more than several months, and may become a disease in itself. In  general, chronic pain management may encompass one or multiple  therapeutic approaches based on a comprehensive patient assessment  made during an evaluation and management (E/M) visit. Such  approaches may include prescription medications, such as opioids;  physical therapy; and chronic pain procedures, such as epidural steroid  injections or nerve blocks. Chronic pain procedures—sometimes referred  to as interventional pain management procedures—are minimally  invasive, but potentially risky. Most of them involve injections, and many  of them occur around the spinal cord. The procedures are typically  furnished in hospital outpatient departments, physician offices, or  ambulatory surgical centers (ASC).

Recently, the issue of which types of health care providers—pain  medicine subspecialists, other types of physicians, or nonphysician  providers, such as advanced-practice nurses—should perform chronic  pain management services has received heightened attention. Some  certified registered nurse anesthetists (CRNA)—a type of advanced- practice nurse specializing in anesthesia care—provide chronic pain  services, as well as other services such as those directly related to  surgical anesthesia. The American Association of Nurse Anesthetists  (AANA) has asserted that CRNAs have demonstrated their ability to  safely and effectively deliver chronic pain management services,  particularly for patients in rural areas where access to pain physicians is  often limited. On the other hand, the American Society of Interventional  Pain Physicians (ASIPP) and the American Society of Anesthesiologists  (ASA) have argued that CRNAs—and to some extent other physicians  without specialized training in pain medicine—are not qualified to  comprehensively and independently treat chronic pain patients, and that  concerns about access should not trump patient safety.

Under federal law, Medicare-covered services of a CRNA include  “anesthesia services and related care.” Until recently, it was unclear  whether this included chronic pain management services, allowing the  Centers for Medicare & Medicaid Services’ (CMS) regional Medicare  Administrative Contractors (MAC) discretion in determining CRNA  coverage. In particular, one MAC—Noridian Healthcare Solutions  (Noridian)—began denying CRNA claims for certain chronic pain  management services in 2011, citing potential patient safety issues. To  clarify the Medicare policy, CMS promulgated a rule that CRNAs can bill  Medicare for “those services that a  is legally authorized to  perform in the state in which the services are furnished,” including chronic  pain management services, effective January 1, 2013. Contrary to the  prior policy, which allowed for MAC discretion, this clarification explicitly  defers to each state’s scope of practice laws to inform whether particular  CRNA services are covered under Medicare.a Medicare standard for the services that can be reimbursed and  recognizes local variation in states’ scope of practice laws.

Thus, CMS’s rule both sets  You asked us to review Medicare’s payment policy regarding the  provision of chronic pain management services by CRNAs. In this report,  we (1) examine trends in Medicare provider billing for selected chronic  pain procedures, (2) determine the extent to which billing for selected  chronic pain procedures changed during the period of Noridian’s payment  denials for CRNAs, (3) identify states in which MACs allowed payment for  selected chronic pain procedures and E/M services billed by CRNAs as of  early 2013, and (4) review how MACs implemented the payment policy  regarding CRNAs.

To address these issues, we selected seven categories of chronic pain  procedures and related current procedural terminology (CPT) codes, in  consultation with pain care experts.procedures billed by CRNAs, we selected procedures that were either  reported by a MAC billing specialist as likely to be used to treat chronic  pain (as opposed to acute pain), or commonly identified by payer  resources as pain management services. For our claims analyses, we  excluded other types of chronic pain management services, such as E/M  and pharmacological services, because of the unavailability of reliable  data. For a description of the selected procedures, see table 1.
subsections: section_title: Background
subsections: section_title: Types of Providers and Practice Requirements
paragraphs: Various types of providers may perform chronic pain management  procedures, and each provider type is subject to certain education,  training, certification, and licensure requirements. The range of chronic  pain management providers and their practice requirements include the  following:

Pain physicians. These physicians have completed a subspecialty  fellowship training program in pain medicine recognized by ABMS.Following medical school and a residency program in a primary  specialty, pain physician candidates must complete an accredited   1-year fellowship and pass an examination to receive board  certification.

Other physicians. Physicians—including those in specialty and  primary care—without certification in pain medicine have  comprehensive medical knowledge through their medical school, as  well as residency training that can last from at least 3 to 7 years.  Although board certification is optional, most physicians take an exam  to become certified in a medical specialty.

CRNAs. According to the AANA, registered nurses with a Bachelor of  Science in Nursing and at least 1 year of experience in an acute  setting can pursue certification in nurse anesthesia. Graduates of  accredited schools of nurse anesthesia, which provide 24 to   36 months of training, must pass a national examination to receive  their certification as CRNAs.

Other nonphysician providers, such as NPs or PAs. To become NPs,  registered nurses undertake advanced clinical training and complete a  master’s program—lasting 1½ to 3 years—or a doctoral program. PAs  typically undertake roughly 2 years of master’s-level training. Both  NPs and PAs must be nationally certified.

Providers must be licensed by the states in which they practice and  adhere to state requirements. Physician and PA licensure is administered  by state boards of medicine, while nursing licensure is administered by  state boards of nursing. Furthermore, all providers are governed by state  laws. For example, NPs may or may not be allowed to practice  independently or prescribe medications depending on the state in which  they practice, and PAs are generally allowed to prescribe medications,  but must practice under the supervision of a physician. These laws can  take precedence over other location- or payer-specific policies, such as  hospital-based privileging.

section_title: Medicare Coverage and Payment for Chronic Pain Procedures
paragraphs: Although CMS has not issued a national coverage determination (NCD)  for chronic pain management, some MACs have established local  coverage determinations (LCD) for chronic pain procedures. Typically,  these LCDs do not address which types of providers may bill Medicare for  the services, but rather stipulate certain coverage or billing rules. For  example, for procedures that may be given to a beneficiary in a series, an  LCD may limit payment to no more than three procedures within a year.  LCDs also contain instructions for providers on how to bill Medicare using  various CPT codes and modifiers. A given procedure may have several  CPT codes that indicate where on the body the procedure takes place or  whether additional levels of a procedure were performed. For instance,  paravertebral facet joint injections would be billed using one CPT code to  indicate a cervical or thoracic location, and another CPT code to indicate  a lumbar or sacral location—as well as “add-on” codes to specify when  injections occurred on multiple levels of the spine.

CMS uses a physician fee schedule to determine the amounts paid to  providers for each CPT code billed. Nonphysician providers of chronic  pain procedures vary in the percentage of the physician fee schedule they  receive. For example, while CRNAs are generally paid 100 percent of the  amount a physician is paid for a given procedure under the physician fee  schedule, NPs and PAs are generally paid 85 percent of the physician fee  schedule.

section_title: CRNAs Billed for Few Selected Chronic Pain Procedures, Most of Which Were in Rural Areas
paragraphs: From 2009 through 2012, CRNAs billed Medicare FFS for a small share  of our selected chronic pain procedures, while pain physicians and other  physicians billed for the largest shares. Of the procedures billed by  CRNAs, most were billed by CRNAs in rural areas until 2012.
subsections: section_title: CRNAs Billed for a Consistently Small Share of Selected Procedures, While Pain Physicians Billed for about 40 Percent of the Procedures Yearly
paragraphs: Overall, the various providers’ shares of chronic pain procedures billed to  Medicare did not change much over the study period. (See table 2.) The  share billed by NPs, PAs, and CRNAs combined grew from 1.4 to   2.6 percent, with CRNA’s billing for less than ½ of 1 percent of all chronic  pain procedures in each year. Pain physicians billed for over 40 percent  of the selected procedures over the 4-year period, while other physicians  billed for over half of the selected services each year. From 2009 through  2012, the trends in shares of Medicare payments by provider type were  largely parallel to the trends in their shares of procedures billed. (See  table 2.) Combined, CRNAs, NPs and PAs, received less than 3 percent  of all payments for these services throughout the period.

The pattern of CRNA billing by type of chronic pain procedure shows that  CRNAs consistently billed for less than 1 percent of the total. (See   table 3.)

CRNAs had their largest market share in epidural injections, where  they accounted for 0.9 percent of providers’ billings in 2009; this share  dropped to 0.6 percent in 2012.

CRNAs billed for even smaller shares of facet neurolytic destruction  injections, autonomic nerve blocks, and trigger point injections.

Over time, the mix of procedures that CRNAs billed to Medicare from  2009 through 2012 changed somewhat. (See fig.1.)

Epidural injections represented the largest share—roughly two- thirds—of CRNA-billed procedures, but that share decreased to less  than half over the period.

The share of paravertebral facet joint injections doubled between  2011 and 2012.

Autonomic nerve blocks, facet neurolytic destruction, and trigger point  injections billed by CRNAs held relatively small but growing shares of  CRNA billing.

By state, the trend among CRNAs’ billing for selected chronic pain  procedures was largely stable over the 4-year period. (See app. III for  state-by-state data.)

CRNAs’ share increased by more than 1 percentage point in 2 states,  declined by more than 1 percentage point in 6 states, and remained  largely unchanged in 42 states and the District of Columbia.

States that experienced the most growth in CRNA market share were  New Hampshire and Tennessee, increasing 4.4 and 2.5 percentage  points, respectively.

By 2012, the CRNA share of selected chronic pain procedures was  highest in New Hampshire (5.5 percent), Iowa (4.3 percent), and  Kansas (4.0 percent). In 43 states and the District of Columbia, the  CRNA share remained under 1 percent.

section_title: Of All CRNA-Billed Chronic Pain Procedures from 2009 through 2011, Most Were Rural; In 2012, Urban CRNAs Were Dominant
paragraphs: Although the number of selected chronic pain procedures billed by all  rural providers increased somewhat from 2009 through 2012, the number  of procedures billed by CRNAs in rural areas declined over the period.  (See fig. 2.) Of all CRNA claims for selected procedures, the share  submitted by providers in rural areas fell from 66 percent in 2009 to   39 percent in 2012; meanwhile, the share of selected procedures  nationwide billed by all rural provider types was roughly 11 percent in  both 2009 and in 2012.

In rural markets, provider shares followed the national trends. (See fig. 3.)

Of the chronic pain procedures billed by rural providers, CRNA claims  were a small percentage.

Physicians without board certification in pain medicine billed for the  majority of claims from rural providers; however, this number declined  over time, while pain physicians billed for an increasing share—almost  a third of rural claims in 2012.

section_title: After Noridian Began Denying CRNA Claims, Changes in the Number of Chronic Pain Procedures Billed Varied across Three Selected States
paragraphs: In mid-2011, Noridian began denying certain chronic pain management  services that were billed by CRNAs and maintained this policy through  2012. The denial policy, among other factors, had the potential to affect  beneficiary utilization in the Noridian states where CRNAs billed for  chronic pain management services. We compared all providers’ billing of  selected chronic pain procedures in 2010—the year prior to the denial  policy—with that in 2012—the full year in which the denial policy was in  place—in the Noridian states with the highest share of CRNAs previously  billing for these procedures. In 2009, CRNAs billed for 8 percent of the  selected procedures in Montana, 1.7 percent in Wyoming, and   1.4 percent in South Dakota. During that same year, CRNAs accounted  for 19 percent of selected chronic pain procedures in rural areas of  Montana, 4 percent in rural Wyoming, and less than 1 percent in rural  South Dakota.

The change in chronic procedures billed between 2010 and 2012 was  minimal for the three states overall, but varied by state.providers in those states billed for 28,238 selected chronic pain  procedures—of which CRNAs accounted for 2.6 percent—and they billed  for 28,155 procedures in 2012 when Noridian denied CRNA claims for  these procedures. By state, the number of procedures billed by South  Dakota and Wyoming providers declined by 9.2 percent and 6.7 percent,  respectively, while Montana provider claims grew by 14 percent over the  2-year period. (See fig. 4.)

section_title: As of Early 2013, MACs Allowed Payment to CRNAs for All or Some Selected Chronic Pain Procedures in All but One State and for E/M Services in Roughly Half of the States
paragraphs: Nearly all MACs allowed Medicare payment to CRNAs for some, or all,  selected chronic pain procedures. As of April 2013, six of the nine MACs  had uniform payment policies for CRNA-provided chronic pain procedures  across all states within a jurisdiction. The remaining three MACs varied  their policies for one state within a jurisdiction. At the state level, MACs  reported the following payment policies regarding chronic pain  procedures (see fig. 6): allowed payment to CRNAs for all selected procedures in 19 states, allowed payment to CRNAs for a subset of selected procedures in   30 states and the District of Columbia, and denied payment to CRNAs for all selected procedures in the  remaining state.

In the 30 states and the District of Columbia where MACs allowed  payment to CRNAs for only certain chronic pain procedures, MAC  payment policies indicated substantial variation in the specific procedures  that can and cannot be billed. MACs most commonly denied CRNA  payment for trigger point injections and facet neurolytic destruction,  allowing CRNA payment for these procedures in only two states.  Conversely, MACs allowed CRNAs payment for somatic nerve blocks in   20 states and epidural injections in 16 states. Furthermore, because each  procedure can have multiple CPT codes associated with it, MACs may  choose to only allow CRNAs payment for some of the CPT codes  associated with the procedure and not others. This was the case for  epidural injections, transforaminal epidural injections, autonomic nerve  blocks, and somatic nerve blocks. Figure 7 illustrates the variation in MAC  payment policies for selected CRNA-provided chronic pain procedures in  Florida, Nevada, and Pennsylvania.

In contrast to their policies on chronic pain procedures, MACs were  generally more restrictive regarding payment for CRNA-billed E/M  services. As of April 2013, they reported the following payment policies  for E/M services (see fig. 8): allowed payment to CRNAs for E/M services in 24 states, and denied payment to CRNAs for E/M services in 26 states and the  District of Columbia.

Payment policies for CRNA-provided chronic pain procedures did not  always align with payment policies for E/M services. In the 19 states  where MACs reported that they allowed payment to CRNAs for all chronic  pain procedures, they also allowed payment to CRNAs for E/M services.  However, among the 30 states for which MACs told us that they allowed  payment to CRNAs for only certain procedures, MACs indicated that they  allowed payment for E/M services in 5—California, Florida, Hawaii,  Kentucky, and Nevada—while denying payment for E/M services in the  remaining states and the District of Columbia.

section_title: Faced with Challenges, MACs Inconsistently Implemented CMS’s CRNA Payment Policy
paragraphs: The MACs did not implement CMS’s CRNA payment policy consistently;  three MACs took steps to apply the policy in 2013, while the remaining six  MACs did not. MACs pointed to a number of challenges, including  vagueness in state scope of practice laws, that affected their ability to  implement the policy.
subsections: section_title: Three MACs Took Steps to Implement CMS Policy, While Remaining Six Did Not Revisit Payment Policies for 2013
paragraphs: Three MACs took steps to implement CMS’s 2013 rule on CRNA  payment and updated their CRNA payment policies, when necessary.  CMS officials told us that they rely on MACs to determine whether  CRNAs are allowed to provide specific services by reviewing each state’s  CRNA scope of practice laws. Two MACs made an effort to determine  which services CRNAs are allowed to perform under each state’s scope  of practice laws. One of the two MACs directly reviewed the laws of the  states in its jurisdiction, while the other MAC contacted each state to ask  for its interpretation of the laws. Instead of attempting to interpret state  scope of practice laws, a third MAC posted a new educational article on  its website notifying CRNAs that they are responsible for knowing which  services are allowable under their state laws.

The remaining six MACs did not take steps to revisit their CRNA payment  policies for 2013. Three of the six MACs reviewed the scope of practice  laws for a state in their jurisdictions prior to CMS’s 2013 ruling at the  request of the state or provider groups. For instance, one MAC stated that  when it began its contract in 2009, the CRNA association for one of its  states asked the MAC to consider allowing its CRNAs to be paid for  chronic pain services, citing a long-standing history of providing these  services. At that time, the MAC reviewed the state’s CRNA scope of  practice laws and determined that they did not preclude CRNAs from  providing chronic pain services. It then extended this affirmative payment  policy across all states within its jurisdiction without reviewing further state  laws. When asked about its implementation of CMS’s 2013 CRNA  payment policy, this MAC told us that it had not revisited any state scope  of practice laws.

Two of the six MACs reported that they have overarching policies in place  to determine coverage for all nonphysician provider types and, therefore,  have not taken any steps to implement this latest CRNA payment policy.  For example, one of these MACs noted that nonphysician providers must  submit a request to the MAC to receive payment for a specific CPT code.  The MAC will then review the relevant state scope of practice law and  determine whether to allow payment for that code. The remaining MAC  reported that it was waiting for further instructions from CMS before  implementing the policy.

section_title: MACs Reported Difficulty in Interpreting State Scope of Practice Laws and Other Constraints
paragraphs: MACs discussed a variety of challenges that affected their  implementation of CMS’s CRNA payment policy. Most MACs reported  challenges interpreting state scope of practice laws to make  determinations about which services CRNAs are allowed to provide,  noting that state scope of practice laws are generally vague and lack  details about which specific services CRNAs can perform. MACs that  asked states to provide an interpretation of the scope of practice laws  reported that the states generally were unable to provide definitive  responses. For instance, one MAC that looked into a state’s CRNA scope  of practice in 2010 told us that the process to determine whether the state  law allowed CRNAs to perform chronic pain services was convoluted; the  MAC was directed back and forth between many state and federal  officials and provider groups. Another MAC said that when a  determination could not be made about a state’s scope of practice, it  defaulted to allowing payment for all services approved by the AANA.

A few MACs discussed the difficulty of differentiating between acute and  chronic pain services for payment purposes. Because CPT codes for  services used to treat chronic pain are also used to bill for acute pain care  in the peri-operative setting, one MAC told us that the only definitive way  to determine whether the service was for chronic or acute pain is to  review the medical record. However, some MACs explained that since  chronic pain procedures are typically provided in an outpatient setting,  they can rely on the place of service listed on the claim to make a best  guess at whether the procedure was used to treat chronic pain. In  addition, a few MACs noted that the frequency of the service can also be  an indicator, with multiple injections billed for a patient by the same  provider over a period of time indicating that the procedure was likely  used to treat chronic pain.

Two MACs assumed that Medicare’s rule requiring physician supervision  of anesthesia services provided by CRNAs in hospital and ASC settings  applied to chronic pain services in all settings; this assumption has  potential implications for CRNA billing of chronic pain services. Under this  rule, CRNA-provided anesthesia services furnished in hospital and ASC  settings must be performed under the direction of a physician unless a  state’s governor has opted out of this requirement. CMS guidance  clarifies that this requirement applies to anesthesia services and not to  analgesia services, which are defined to include services used to dull or  alleviate pain without other effects, such as the loss of consciousness; the  guidance does not expressly use the term “chronic pain management.”  These two MACs took the view that they would have needed to review  CRNA scope of practice laws only in states that had opted-out of the  supervision requirement, implying that they considered chronic pain  management services to be anesthesia services. Regardless of the  validity of this interpretation, the supervision rule only applies in hospital  and ASC settings, not office settings. By applying this rule to office  settings, these MACs may have unnecessarily restricted the services for  which CRNAs in 10 of the states under these MACs’ jurisdictions are  allowed to bill.

section_title: Conclusion
paragraphs: Use of state scope of practice laws to govern Medicare coverage of  CRNA-provided chronic pain care continues to be an area of uncertainty  and confusion for many MACs. Similarly, certain MACs have interpreted  the CRNA supervision rule, as it relates to CRNA-provided chronic pain  management services, in a way that may inappropriately limit CRNA  billing for such services when furnished in office settings. As a result,  MACs have not implemented CMS’s 2013 payment rule in a consistent  manner that ensures appropriate beneficiary coverage and provider  payment. Although CRNAs do not bill for a significant share of the chronic  pain procedures we reviewed, if a MAC improperly denies payment to  CRNAs in a state that allows CRNAs to independently furnish such  services, beneficiary access to these services may be unnecessarily  affected.

section_title: Recommendations for Executive Action
paragraphs: In order to ensure consistent implementation of CRNA payment policy,  we recommend that the Administrator of CMS (1) provide specific  instructions to MACs on how to determine coverage with reference to a  state’s scope of practice laws, including instructions on how to proceed if  the state scope of practice laws are not explicit, and (2) clarify the  applicability of the CRNA supervision rule to payment for CRNA-provided  chronic pain management services.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for comment. In its written  response, reproduced in appendix IV, HHS concurred with our two  recommendations. Regarding our recommendation to provide specific  instructions to MACs on how to determine coverage with reference to a  state’s scope of practice laws, HHS stated that CMS plans to send a letter  directing all MACs to seek clarification from appropriate state officials or  entities if state scope of practice laws are not explicit. Regarding our  recommendation to clarify the applicability of the CRNA supervision rule  to payment for CRNA-provided chronic pain management services, HHS  stated that CMS will clarify that the supervision rule governs only  anesthesia services furnished in hospitals or ASCs. HHS also provided  technical comments that we incorporated as appropriate.

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section_title: Appendix I: Scope and Methodology
paragraphs: This appendix describes our methodology for analyzing recent trends in  billing for selected chronic pain procedures, as well as changes in the  number of procedures billed during the period of Noridian Healthcare  Solutions (Noridian) denials. It also describes our efforts to ensure the  reliability of the data.
subsections: section_title: Selection of Procedures
paragraphs: We focused our review on a set of seven categories of chronic pain  procedures and corresponding current procedural terminology (CPT)  codes. To select procedures, we obtained an American Association of  Nurse Anesthetists (AANA) list of CPT codes that are billed by certified  registered nurse anesthetists (CRNA). We categorized the CPT codes by  procedure, in consultation with nurse and physician pain experts. We  narrowed this list to procedures that were either reported by a Medicare  Administrative Contractor (MAC) billing specialist as most likely to be  used in treating chronic pain (as opposed to acute pain), or those  commonly mentioned across payer resources—such as local coverage  determinations (LCD)—as pain management options. We excluded other  types of chronic pain management services, such as evaluation and  management (E/M) and pharmacological services because of the  unavailability of reliable data. The procedures we selected to include  were: autonomic nerve blocks, paravertebral facet joint injections,  trigger point injections.

This category excludes codes used for emerging technologies, services, or procedures.

section_title: Analysis of Medicare Claims Data
paragraphs: To determine trends in billing for the selected procedures, we analyzed  100 percent of Medicare fee-for-service (FFS) paid claims from 2009  through 2012. We calculated the number of procedures billed to  Medicare FFS from the carrier/physician file, excluding claims billed by  some critical access hospitals. We considered procedures administered  on more than one vertebral level of the spine to be separate procedures.  We derived overall expenditures for selected chronic pain procedures  from both provider payments (through the physician/carrier file) and  outpatient facility payments (through the outpatient file).

We took additional steps in an effort to narrow our focus to procedures  used to treat chronic pain. First, we excluded claims for procedures billed  as distinct procedural services during the same encounter as another  procedural service, where normally both would not be billable. We  confirmed with several Medicare or chronic pain billing experts that, while  not exclusively, these procedures are more likely than not to be for acute  pain occurring in conjunction with another procedure. Additionally, we  excluded claims in the carrier/physician file for procedures performed in  the hospital inpatient setting. Several MACs told us that chronic pain is  treated almost exclusively in outpatient settings. While these steps  mitigated overcounting the number of chronic pain procedures, our  analysis may still include some acute procedures and may exclude some  chronic procedures.

We disaggregated biller (provider) type based largely on the provider  specialty indicated on the claim.physician biller type. To identify physicians that are board certified in pain  medicine—pain physicians—we cross-referenced the names of  physicians provided by the American Board of Medical Specialties  (ABMS) as board certified in pain medicine, to a list of all Medicare  providers, as maintained by the Centers for Medicare & Medicaid  Services (CMS) through the National Plan and Provider Enumeration   The exception to this is the pain  System (NPPES).match 91 percent of the pain physicians to NPPES records. We then  used the provider identifier from the NPPES data to identify pain  physicians on the claims.

Using a name-matching strategy, we were able to  Our count of procedures provided by nonphysicians may be conservative.  For example, physicians and certain other providers may bill “incident  to”—whereby, for example, a physician might bill for a supervised service  or procedure furnished by a nurse practitioner (NP), physician assistant  (PA), or CRNA. There is no way on the claim to determine when a service  is billed “incident to,” rather than provided completely by the billing  professional. Services billed “incident to” indicate the specialty of the  billing professional. To the extent that nonphysician professionals  provided services in whole or in part that were billed “incident to” another  professional, we may have undercounted procedures provided by  CRNAs, NPs, or PAs. In addition, providers, including pain physicians,  can reassign their billing so that their employer may bill on their behalf. In  this case, the provider identifier on the claim would be that of the  employer, and we would not capture the provider as a pain physician  based on our name matching strategy.

We also disaggregated the data by geographic location. To analyze urban  and rural biller (provider) status, we used the CMS Core-Based Statistical  Area crosswalk to identify those rural providers as providers with a zip  code that is not associated with a Core-Based Statistical Area.

section_title: Changes in Billing during the Period of Noridian Denials
paragraphs: To determine the extent to which the number of selected chronic pain  procedures billed to Medicare FFS changed during the period of denials,  we analyzed Medicare FFS claims from 2009 through 2012 in those  states under Noridian’s jurisdiction that were subject to CRNA denials and  under Noridian’s jurisdiction for all 4 years of the study period. At the time  of our analysis, Noridian’s jurisdiction included Alaska, Arizona, Idaho,  Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and  Wyoming. We excluded Washington state, where CRNAs are dually  trained as NPs, and thus not subject to the denials. We also excluded  Idaho because it was under another contract until 2011. We then limited  our analysis to those states where CRNAs constituted at least 1 percent  of the chronic pain provider market in 2009: Montana, South Dakota, and  Wyoming. We measured the overall number of procedures billed to  Noridian for the same set of selected chronic pain procedures, using the  same methodology as in the broader trend analysis. We compared billing  for selected chronic pain procedures prior to the MAC denials—which  began in 2011—to billing in 2012 when the MAC denial policy was fully  implemented. We assessed the trend both state-wide and in rural areas.

section_title: Data Reliability and Audit Standards
paragraphs: We ensured the reliability of the Medicare claims data, ABMS pain  physician data, and NPPES data used in this report by performing  appropriate electronic data checks, reviewing relevant documentation,  and interviewing officials and representatives knowledgeable about the  data. We found the data were sufficiently reliable for the purpose of our  analyses.

We conducted this performance audit from March 2013 through February  2014 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

section_title: Appendix II: Overall Trends in Billing by Selected Procedure
paragraphs: From 2009 through 2012, the number of selected chronic pain procedures  billed to Medicare fee-for-service (FFS) grew by about 5.7 percent  annually, while Medicare spending on these procedures grew at a slightly  higher rate. (See tables 4 and 5.) Growth rates varied across procedures;  for example, claims for somatic nerve blocks and paravertebral facet joint  injections rose more rapidly at about 11 percent and 9 percent per year,  respectively, while claims for epidural injections rose by about 2 percent  annually.

Overall, Medicare payments for selected chronic pain procedures  increased somewhat faster than the number billed, rising 6.5 percent  annually between 2009 and 2012. (See table 5.) This rate of growth is  above the average growth rate of 5.3 percent per year in overall Medicare  Part B spending over the same period. As with the trend in the number  billed, average annual growth in expenditures varied across selected  chronic pain procedures; expenditures grew most rapidly for somatic  nerve blocks (20 percent annually) and facet neurolytic destruction   (13 percent annually), while expenditures for epidural injections grew  least rapidly (5 percent annually).

section_title: Appendix III: CRNA Share of Selected Chronic Pain Procedures, by State
paragraphs: This appendix provides further detail on how certified registered nurse  anesthetists’ (CRNA) market share of selected chronic pain procedures  changed between 2009 and 2012, by state.

section_title: Appendix IV: Comments from the Department of Health and Human Services

section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Rosamond Katz, Assistant  Director; Sandra C. George; Richard Lipinski; Kate Nast; and   Kathryn Richter made key contributions to this report.


Question-summary annotations: questions: question: What did certified registered nurse anesthetists do from 2009-2012?
answer: From 2009 through 2012, certified registered nurse anesthetists (CRNA)—a type of advanced-practice nurse specializing in anesthesia care—billed Medicare fee-for-service (FFS) for a minimal share of selected chronic pain procedures, less than ½ of 1 percent of these procedures in each year.
child_questions: question: What did physicians without board certification in pain medicine do?
answer: Physicians without board certification in pain medicine billed for the majority of selected procedures each year, while pain physicians consistently billed for roughly 40 percent of selected procedures.

question: What happened to the number of procedures billed by rural CRNAs?
answer: Furthermore, although the number of chronic pain procedures billed by all rural providers increased from 2009 through 2012, the number of procedures billed by rural CRNAs declined over the period.

question: What happened to the share billed by CRNAs in rural areas?
answer: Of all CRNA claims for selected procedures, the share billed by CRNAs in rural areas fell from 66 percent in 2009 to 39 percent in 2012.

questions: question: What is chronic pain’s national financial cost?
answer: Chronic pain costs the nation about $600 billion each year, a quarter of which is borne by Medicare.

question: What did Noridian Healthcare Solutions begin doing?
answer: One MAC, Noridian Healthcare Solutions (Noridian), began denying CRNA claims for certain chronic pain services in 2011, citing patient safety concerns.

question: What rule did CMS issue, effective January 2013?
answer: CMS issued a rule, effective January 2013, clarifying that CRNAs can bill Medicare for “any services that a [CRNA] is legally authorized to perform in the state in which the services are furnished,” including chronic pain management services.

question: What was GAO asked to do?
answer: GAO was asked to review Medicare's payment policy regarding the provision of chronic pain management services by CRNAs.
child_questions: question: What does this report examine?
answer: This report examines, among other things, (1) trends in Medicare provider billing for selected chronic pain procedures; (2) in which states MACs allowed payment for selected procedures billed by CRNAs as of early 2013; and (3) how MACs implemented the payment policy.

question: How does this report examine this?
answer: To do this, GAO selected seven categories of chronic pain procedures, in consultation with pain care experts. GAO analyzed Medicare claims data from 2009 through 2012, by provider type and geography. To determine which MACs allow CRNA payments and how MACs implemented CMS's policy, GAO interviewed medical directors at all nine MACs.