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Certified Registered Nurse Anesthetist (CRNA) Exemption to the Fee Schedule
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Under the provisions at 42 CFR 412.113(c), a rural hospital or Critical Access Hospital (CAH) may qualify to receive anesthesiology services furnished by employed or contracted nonphysician anesthetists (Certified Registered Nurse Anesthetist(CRNA)/Anesthesiology Assistant(AA)) at cost versus the fee schedule. This election is made on a calendar year by calendar year basis. It is the provider's responsibility to request and supply all supporting documentation to determine if the qualifications listed at 42 CFR 412.113(c) are met. Documentation sent to the contractor must be postmarked by December 31st of each year.
Qualifications per 42 CFR 412.113(c):
- To be geographically located in a rural area under 42 CFR 412.62(f).* Effective December 2, 2010, this also includes providers that have been reclassified to rural under 42 CFR 412.103.
- Some CAH facilities may be geographically reassigned to urban regions under the Core Based Statistical Area (CBSA) designation. In those instances where special exemption has been granted by the CMS Regional Office for the hospital to retain their CAH status in the urban geographical region, a copy of the CMS exemption letter should be sent along with the supporting documentation.
- Some CAH facilities may be geographically reassigned to urban regions under the Core Based Statistical Area (CBSA) designation. In those instances where special exemption has been granted by the CMS Regional Office for the hospital to retain their CAH status in the urban geographical region, a copy of the CMS exemption letter should be sent along with the supporting documentation.
- The hospital/CAH must have employed or contracted with a qualified nonphysician anesthetist(s) to perform services in that hospital/CAH as of January 1, 1988.
- If a facility did not employ or contract with a qualified non-physician anesthetist on that date, they will never be eligible for CRNA pass through payment under current regulations. This requirement is due to the fact that the CRNA pass through is a hold harmless type payment, holding the provider harmless from changes that were made back when CRNA was first converted from cost to fee schedule. If the provider never received cost reimbursement in the first place (on January 1, 1988), there is nothing to be held harmless from and they will be reimbursed under fee schedule.
- If a facility did not employ or contract with a qualified non-physician anesthetist on that date, they will never be eligible for CRNA pass through payment under current regulations. This requirement is due to the fact that the CRNA pass through is a hold harmless type payment, holding the provider harmless from changes that were made back when CRNA was first converted from cost to fee schedule. If the provider never received cost reimbursement in the first place (on January 1, 1988), there is nothing to be held harmless from and they will be reimbursed under fee schedule.
- The volume of inpatient and outpatient surgical procedures (see the surgical section of the CPT manual for a list of surgical procedures) requiring anesthesia services did not exceed 800 procedures in the prior calendar year. (Federal Register/Vol.67, No.148/Thursday, August 1, 2002).
- Note that when reviewing the “prior calendar year”, only the first 9 months of that year are needed, as described in 42 CFR 412.113(c)(2)(iv). The 800 procedure count is always based on that prior period data. No review of updated current year data is performed on these procedures.
- Note that the regulatory reference to the initial procedure count in the 1987 calendar year applied only because that was the prior year to 1988. Failure to meet the procedure count in any year (including 1987) only means that next year will not be eligible for CRNA pass through. Unlike the “employed/contracted as of 1/1/1988” criterion above, failure to meet this procedure count does not bar a provider from being eligible for CRNA pass through in a future year.
- The hospital/CAH must employ or contract with a qualified nonphysician anesthetist(s) to perform services in that hospital/CAH in the current calendar year, but the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year (1 FTE). These hours represent total hours at the hospital (not just in surgery) and include time spent in furnishing anesthesia services to patients and general services to the hospital
(Federal Register/Vol. 57, No. 148, Friday July 31, 1992).- Failure to meet this criterion in the current year only affects current year eligibility. If there is evidence to show that a provider exceeded the allowable 2,080 hours (regardless of how many CRNAs they have employed), then they will lose their pass-through eligibility status. Note that since this is a current year eligibility requirement, it could not possibly be part of the approval process completed by January 1st of each year. As such, failure to maintain the 2,080-hour limit will result in retroactive CRNA denial, thus disallowing any Medicare charges from the claims billed as CRNA revenue code 964. It is up to the provider to rebill those claims as fee schedule within the appropriate time limits.
- Failure to meet this criterion in the current year only affects current year eligibility. If there is evidence to show that a provider exceeded the allowable 2,080 hours (regardless of how many CRNAs they have employed), then they will lose their pass-through eligibility status. Note that since this is a current year eligibility requirement, it could not possibly be part of the approval process completed by January 1st of each year. As such, failure to maintain the 2,080-hour limit will result in retroactive CRNA denial, thus disallowing any Medicare charges from the claims billed as CRNA revenue code 964. It is up to the provider to rebill those claims as fee schedule within the appropriate time limits.
- Each qualified nonphysician anesthetist under contract or employed by the hospital or CAH has agreed in writing not to bill on a reasonable charge basis for his/her patient care to Medicare beneficiaries.
Examples of supporting documentation may include the following:
- Copies of CRNA/AA contracts (for 1988 requirement, as well as for current year requirements.) If the CRNA/AA is employed by the hospital/CAH, the CRNA exemption request submitted by the facility should indicate that the CRNA/AA is an employee of the hospital/CAH.
- Payroll documentation (to support the 1988 requirements as well as the current calendar year requirements.)
- Supporting documentation to define the total number of hours spent at the facility, whether performing anesthesia or other services.
- A signed statement by each CRNA/AA agreeing that he/she will not bill on a fee schedule basis for patient care services. This statement must include the current review period.
- A surgical log with dates of procedures that were performed between January 1st and September 30th of the current year. The log must contain:
- Surgery Date
- Patient Name
- Surgeon Name
- Anesthetists' Name (CRNA/AA)
- Type of Anesthesia
- Type of Surgical Procedure
This information may be submitted to the contractor by means of electronic media (such as Compact Disc). Due to the presence of PHI/PII, data should be password protected and communicated to Reimbursement.Overpayment.Inquiry@wpsic.com. This provides a level of protection not available with paper copies.
If WPS GHA notifies your hospital that it qualifies for reasonable cost reimbursement for nonphysician anesthetist services, please be aware your hospital must continue to meet all the requirements in 42 CFR §412.113(c) for the year in which reasonable cost reimbursement has been approved. For example, your hospital submits information for the period January 1, 2018, to September 30, 2018, and WPS GHA, based on our review of that information, notifies the hospital it qualifies for cost reimbursement in 2012. If we audit nonphysician anesthetist reimbursement at final settlement of the hospital's cost report that begins in 2012 and conclude the hospital has not met the §412.113(c) requirements during the cost reporting period, we will disallow all cost reimbursement for nonphysician anesthetist services in that period.
Note: The CRNA Pass Through Payment is available ONLY for the hospital itself; not any subunits or swingbeds. If any other units have billed services under the CRNA revenue code 964, these Medicare charges will be excluded from the cost report, as they should have been billed under fee schedule, which is normally not allowed on the cost report. This will ensure that no cost-based reimbursement is erroneously calculated. It is incumbent upon the provider to properly bill their subunit/swingbed CRNA claims as fee schedule to ensure they receive reimbursement for them.
For questions, please contact the WPS GHA Reimbursement Process Coordinator or the WPS GHA Audit Supervisor assigned to your facility.
global-tags: J8A,J5A,Reasonable Cost,Fees and Reimbursement,Certified Registered Nurse Anesthetist (CRNA),Audit
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