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Financial Considerations of an Anesthesia Consult Service
ARTICLE IN PRESS Journal of Cardiothoracic and Vascular Anesthesia 000 (2018) 1 7
Contents lists available at ScienceDirect
Journal of Cardiothoracic and Vascular Anesthesia journal homepage: www.jcvaonline.com
Special Article
Financial Considerations of an Anesthesia Consult Service 1
Thomas E. Schulte, MD , Amy L. Duhachek-Stapelman, MD, Austin J. Adams, MD, Tara R. Brakke, MD, Ellen K. Roberts, MD Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
Surgical patients with complex cardiac disease often require noncardiac surgery. There have been recent articles written concerning the role of the cardiothoracic anesthesiologist as a consultant in the operating room as well as outside the operating theatre.1,2 With the evolution of the cardiothoracic anesthesia consult service (CACS), there are many issues regarding medical billing, financial reimbursement, and Medicare rules that anesthesiologists may not be familiar with. This paper will discuss the financial implications of starting a CACS. Ó 2018 Elsevier Inc. All rights reserved. Key Words: cardiac anesthesia consult service; adult cardiothoracic anesthesia; perioperative evaluation; financial considerations of anesthesia billing
Background A paradigm shift has occurred in recent years regarding the preoperative assessment and optimization of surgical patients. The Perioperative Surgical Home model was developed as a method to improve clinical outcomes and decrease costs due to enhanced coordination of care in the perioperative period.3 The goal is not to minimize the benefits of pr-operative evaluation by a patient’s primary care provider or cardiologist. This physician has the most intimate knowledge of the patient’s medical history and can provide excellent insight into their level of presurgical optimization. However, there are nuances of anesthetic care that may not be recognized by the primary care physician or cardiologist. These include developing the anesthetic plan, determining the need for invasive monitoring, and assessing which steps in a surgical procedure might be associated with a high risk for patient decompensation. Postoperative concerns such as the plan for pain management, necessity for ventilation, or advanced hemodynamic support also may not be within the scope of the primary care physician’s level of expertise concerning the operative course. To address these issues in patients with significant cardiovascular Each author has written a part of the paper and agrees with the final draft. 1 Address reprint requests to Thomas E. Schulte, MD, Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE 68198-4455. E-mail address: [email protected] (T.E. Schulte). https://doi.org/10.1053/j.jvca.2018.12.007 1053-0770/Ó 2018 Elsevier Inc. All rights reserved.
disease, the authors built a successful cardiothoracic anesthesiology consult service at the authors’ institution. The authors will describe the importance of this service for patient care, as well as review the authors’ business plan for its development. Preoperative Evaluation by Nonanesthesiologists There have been mixed results regarding the benefit of preoperative assessment and optimization by nonanesthesiology specialists. To assess the benefit of preoperative consultation by internal medicine physicians, a systematic review of the literature was performed to analyze length of hospital stay, cost, morbidity, and mortality as well as quality of life in high-risk surgical patients.4 Only 4 of 128 citations screened met inclusion criteria, and they found the quality of available evidence to be poor.5 8 However, based upon the available data, the authors concluded that there was positive effect of preoperative consultation by a general internist. Conversely, a cohort study was performed using a population-based administrative database, in which 38.8% of 269,866 patients underwent consultation by internal medicine in the preoperative period. Compared to a matched cohort, patients receiving consultation had an increase in both 30-day mortality (relative risk 1.16) and 1-year mortality (relative risk 1.08), an increased mean hospital stay of 0.67 days, as well as an increase in preoperative testing and pharmacologic interventions.9 Based upon this and other work, the benefit of preoperative internal medicine consultation requires further evaluation.
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Preoperative Evaluation by Anesthesiologists In contrast to what has been published on the preoperative evaluation of patients by nonanesthesiologists, several studies have shown benefits of the anesthesiologist as a preoperative consultant.10 13 Blitz and colleagues performed a retrospective administrative database review of over 64,000 surgical patients, of which 55.2% were seen in the anesthesiologist-led preoperative evaluation clinic (PEC).10 Propensity-matched scoring resulted in 13,964 patients in each matched set, with 11 deaths in the PEC group and 23 deaths in patients not seen in the PEC. In this study, a visit to the PEC was associated with decreased mortality (odds ratio 0.48%, p = 0.04) compared to matched cohorts. Beneficial results also were found in a populationbased cohort study performed over 10 years, which analyzed 271,082 patients who underwent elective intermediate- to highrisk noncardiac surgery from 1994 to 2004.11 Thirty-nine percent of patients underwent anesthesia consultation in the preoperative period. Consultation was associated with a decrease in mean hospital length of stay (8.17 v 8.52 days, p < 0.001) in these patients; however, there was no difference in postoperative survival. Finally, studies have shown a decrease in operating room (OR) delays and cancellations when the patient is seen in the anesthesia preoperative medicine clinic.12 An additional observational study revealed a significant reduction in case cancellation, as well as a decrease in length of admission.13 The improved outcomes and decreased delays and cancellations in these patients may be owing to an understanding of the nuances of anesthetic care that are not a part of the internal medicine consultant’s area of expertise. Data regarding improvements in length of stay and mortality with preoperative consultation by an anesthesiologist provide support for assessment and optimization. It may follow that even further improvements will occur when consultation is performed by experts in the operative care of cardiac patients presenting for noncardiac surgery. Further studies will help to elucidate if the utilization of cardiac anesthesiology consultants for patients with complex cardiac diseases will lead to improved outcomes in these patients. Within the specialty of anesthesiology, there is variability in expertise in caring for certain subsets of patients. For example, not all anesthesiologists are familiar with congenital cardiac disease, advanced mechanical support devices, or the care of patients with critical valve disease or end-stage cardiac disease. It is in these patients that consultation by the cardiothoracic anesthesia consult service (CACS) has the potential to provide the most benefit. The CACS provides value in preoperative risk assessment, intraoperative hemodynamic monitoring, echocardiography skills, and postoperative direction in patients with complex cardiac disease presenting for noncardiac surgery.2 Efficiency in the OR There are several important resources in the perioperative area, some of which include time, testing/equipment, and personnel. The development of a CACS may lead to appropriate utilization of these resources through a number of mechanisms.
The first of these mechanisms is the cost of OR time when a case is delayed or canceled. The cost estimate of OR time has been found to be highly variable. Although the authors do not know the exact cost of running an OR, underutilized OR time is a significant expense. Published estimates vary quite widely, from $21/min to $133/min.14,15 The incorporation of a CACS into a clinical practice may prevent delays of surgical care for noncardiac procedures. The hospital then may realize financial benefits through a decrease in wastage of the costly resource of OR time through the development of mechanisms to minimize delays and cancellations. For example, consultation may lead to performance of an echocardiogram earlier in the patient’s care, avoiding a last-minute delay waiting for additional tests. Conversely, after evaluation by the CACS, it may be determined that the patient needs no further workup, which will allow the procedure to continue on schedule. Finally, if it is determined after CACS evaluation that the patient does not need to be cared for by a cardiothoracic anesthesiologist (CTA), an appropriate care team can be assigned to the procedure, thereby avoiding unnecessary delays. This scenario would allow the case to be done during prime-time OR hours, rather than after the CTA finished their cardiac case, decreasing OR personnel overtime. Hospitals also may see an improved optimization of the use of important resources, such as the need for an echocardiogram or referral to the patient’s cardiologist for stress testing or medical optimization. The CACS also may limit unnecessary testing and thereby decrease healthcare expenditures. The goal in these cases is to use resources when they clearly are indicated and avoid unnecessary interventions. This also will optimize the use of equipment, which is yet another valuable resource. In addition to the above mechanisms, the use of personnel resources in an appropriate staffing model can lead to financial benefit. Personnel costs make up most of the operating expenses, therefore it is important to match an efficient staffing model to needs.16,17 In a previous article, the authors discussed how to estimate needs and therefore the required personnel number for providing the service.2 With decreasing reimbursement rates and increasing demands for expanding services, most anesthesiology practices require hospital subsidization to balance their budget.17,18,19 Although hospital stipends for anesthesia services are common, the expectation remains to contain or decrease costs. One way to minimize cost of the service is to create a staffing model that does not require additional full-time-equivalent CTA providers but still allows for the institution of a CACS. Staffing a CACS When developing a staffing model, it is necessary to determine whether a CTA can cover consults while simultaneously covering an OR site. This model would allow the consults to occur without disrupting scheduled OR cases. This should be an option if the OR staffing model consists of an anesthesiologist medically directing a resident, fellow, or certified nurse anesthetist. At the authors’ institution, the CTA covers 1 site while medically directing a resident or fellow (1:1 staffing ratio). The on-call CTA covers the CACS and has the responsibility to find coverage for all
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the consults. This often means delaying the consult until one of the CTA team members is available to evaluate the patient for the CACS after their OR cardiac case. Although this may be reasonable for inpatient consults, this model is impractical for consults in the anesthesia pre-evaluation clinic. The time-sensitive nature of evaluating these patients would be better served with the staffing model discussed below. An additional option is to have one of the CTAs medically direct 2 sites (1:2 staffing ratio), while the second room’s CTA performs the consult. Ensuring that the second site is covered by a CTA who is not the primary anesthesiologist covering the consult allows reimbursement for the consult. This flexibility in staffing allows for all scheduled operations to continue, the consult to be performed and evaluated in real time, and full reimbursement of the consult performed to occur. This coverage must be reflected in the electronic health record (EHR) because anesthesiologists are not able to bill for consult services outside the OR while simultaneously performing OR duties. The authors find this method of coverage to be the most practical and appreciated by the surgeons owing to the timeliness of the consult. Also, performing the consults while on cardiopulmonary bypass allows for the most opportunistic timing of the consult to be performed, as rarely is direct supervision required while on cardiopulmonary bypass. The CACS also could use personnel during their nonclinical time, as some academic groups offer this time to faculty. With this model, the CACS would require at least 1 team member to be nonclinical each day. In the authors’ experience, this model is not well received because most faculty view this as a loss of valuable time needed to pursue academic goals. The authors acknowledge that developing a staffing model in a physician-only group is more challenging. The consult could be done only after the scheduled cases, which would be fine for future surgical cases. However, this would not allow emergency consults in the OR due to patient decompensation, or in the preoperative area when the CTA physician is working solo in the OR. The OR is the financial machine of the hospital. Examples of the overall positive financial benefits of a CACS include decreasing the number of OR delays, increasing first case on time start percentage, and using OR personnel during primetime hours. When expanding services, the anesthesiology group needs to minimize costs while simultaneously developing a safe, efficient, quality-driven service. Billing Historically, billing for consultation services relied upon submitting Current Procedural Terminology (CPT) consultation codes developed and maintained by the American Medical Association to the patient’s insurance provider, along with the necessary supporting documentation of the services provided. However, as of January 2010, the Centers for Medicare and Medicaid Services (CMS) no longer recognizes or pays for consultation services using CPT consultation codes. Instead, providers now are required to report patient evaluation and management (E/M) codes for all services submitted to CMS for reimbursement, including those previously reported as CPT consultation
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codes.20 At the time of the change, this became problematic because many third-party or commercial payers still accepted the CPT consultation codes for reimbursement. In the years since, many third-party payers also have moved away from the CPT codes, now relying on the E/M codes used by CMS. Such an alignment in coding has helped simplify billing in most instances, but a limited number of commercial payers still accept the CPT consultation codes. At the authors’ institution, all requests for reimbursement of consultation services use the currently accepted standard E/M codes. Initially established by Congress in 1995 and revised in 1997, E/M standards and guidelines provide a unified method for medical billing. Evaluation and management codes reflect where a service was provided (inpatient v outpatient), but also require the provider to identify the level of complexity of medical decision-making required in providing care to a given patient.21 Following the elimination of CPT consultation codes, consultant physicians perform and bill insurance providers for what amounts to a history and physical (H&P), although the encounter may be documented as a “consult” within the patient’s EHR. To prevent the appearance of multiple H&Ps for billing purposes, the admitting physician must attach a modifier to the initial H&P to identify themselves as the primary physician of record (CMS 1). Consultant physicians should not attach the modifier to their billing code. Under E/M coding guidelines, a H&P/consult note must contain 3 key components: a history, physical exam, and medical decisionmaking. History, the first key component of E/M documentation, is subdivided further into the chief complaint; history of present illness (HPI); review of systems; and past medical, family, and social history. Based on the level of documentation, the history section can be categorized as “problem focused,” “expanded problem focused,” “detailed,” or “comprehensive” (Table 1). The second key component of E/M documentation is the physical exam. The physical exam also can be categorized into 4 levels: “problem focused,” “expanded problem focused,” “detailed,” and “comprehensive” based on the number of organ systems examined and the degree of documentation (Table 2). A cardiovascular exam may be substituted in lieu of a general multisystem exam, but the documentation requirements are different from those identified in Table 2. Medical decision-making is the final key component for E/M documentation. Medical decision-making represents the complexity of information being managed. Similar to the H&P exam components, medical decision-making is subdivided further into 4 categories, including “straightforward,” “low complexity,” “moderate complexity,” and “high complexity.” The level of medical decision-making is dependent upon the number of diagnoses, the amount and complexity of data being reviewed, as well as the risk of complication and/or morbidity and mortality to the patient (Table 3).21 Under the new guidelines set forth in January 2010, physicians report “consultations” on inpatients using initial hospital care E/M codes 99221 to 99223. Billing for E/M codes 99221 to 99223 requires that a minimum of the key components for work and/or medical necessity must be documented and met.20 If the minimum key components for codes 99221 to 99223 cannot be met for a given encounter, providers are
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Table 1 History: The First Component of Evaluation and Management (E/M) Codes1 Type of History
HPI
ROS
PMFSH
Problem focused Focused expanded problem Detailed
Brief (1-3 elements) Brief
N/A Problem pertinent (system directly related to problem) Extended (2-9 systems)
N/A N/A
Complete
Extended (>4 elements or s tatus >3 chronic conditions) Extended
Complete (>10 organ systems)
Pertinent (at least 1 item from any of 3) Complete (>1 item for each of 3 areas)
Abbreviations: E/M, evaluation and management; HPI, history of present illness; ROS, review of systems; PMFSH, past medical, family, and social history.
Table 2 Multisystem Exam: The Second Section of E/M Codes1 Type of Exam Problem focused Expanded problem focused Detailed Comprehensive
1-5 elements in 1 or more organ systems >6 elements in 1 or more organ systems >2 elements from 6 organ systems or >12 elements from 2 or more systems All elements in at least 9 organ systems or >2 elements from 9 organ systems
Abbreviations: E/M, evaluation and management.
allowed to use the subsequent hospital care visit E/M codes 99231 or 99232.20 Billing of E/M codes 99221 to 99223 may occur based on the level of documentation or based on time (Table 4). When billing is based on the level of documentation, the level of all 3 components (history, physical exam, and medical decision-making) must be sufficient to meet the minimum requirements for that particular E/M code. For CMS, a 99221 evaluation carries a value of 1.92 relative value units (RVUs) (approximately $104), a 99222 evaluation is 2.61 RVUs (approximately $138), and 99223 is 3.86 RVUs (approximately $204). Time-based billing carries no specific requirements for documentation of a history, physical exam, or medical decisionmaking, although it is recommended strongly to include this information in the consultation note. For consultation services, time-based billing is only for time spent in face-to-face consultation with the patient, and does not include time spent on the patient’s floor reviewing medical records or in discussion with house medical staff.22 The duration of the encounter must be documented when time-based billing is used. Regardless of
the decision to bill based on medical necessity or time, appropriate documentation is paramount.21 As discussed earlier, when billing for time-based patient consultation, the anesthesiologist cannot be staffing an OR while performing the consultation. At the authors’ institution, no additional medical billers were hired, nor was any additional training needed for the medical biller. Because the authors also have a critical care anesthesiology service, the billers were familiar with the codes and requirements needed at each level. For a formal consult to occur, the requesting physician must place an order in the EHR requesting evaluation by a CTA (Fig 1). Within the authors’ EHR, the authors have created an order to consult cardiac anesthesiology. This order is titled “Inpatient Consult to Cardiac Anesthesiology.” Once the order has been placed, the requesting provider then contacts the anesthesiology clinical director or the “board runner,” informing them that a request has been made for evaluation by cardiac anesthesiology, and the request is relayed to the CTA on call. At the authors’ academic institution, often the consultation evaluation first is performed by the adult cardiothoracic anesthesiology fellow, and subsequently staffed by the attending CTA after a discussion of the patient and direct evaluation by the attending. This allows for education of the fellow not only about the cardiac disease of the patient but also medical billing. In many instances, the imaging and laboratory studies are reviewed prior to performing the physical consultation. Sometimes the clinician performing the consult is not the same clinician who will provide the anesthetic, so including the results of the studies in the consultation note not only helps inform the authors’ colleagues about the patient’s medical condition, but also prevents them from having to dig through the chart to find the desired information. Additionally, including such information in the consultation note helps support the
Table 3 Medical Decision-Making: The Third Component of E/M Codes1 Type of Decision-Making
Number of Diagnoses or Management Options
Amount and/or Complexity of Data to Be Reviewed
Risk of Complications and/or Morbidity or Mortality
Straightforward Low complexity Moderate complexity High complexity
Minimal Limited Multiple Extensive
Minimal Limited Moderate Extensive
Minimal Low Moderate High
Abbreviations: E/M, evaluation and management.
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Table 4 E/M Codes2 E/M Code
History
Physical Exam
Medical Decision-Making
Time
99221 99222 99223
Detailed or comprehensive Comprehensive Comprehensive
Detailed or comprehensive Comprehensive Comprehensive
Straightforward or low complexity Moderate complexity High complexity
30 min 50 min 70 min
Abbreviations: E/M, evaluation and management.
medical decision-making component of billing, and clinical documentation is paramount in supporting billing. Medical decision-making is determined by 3 components, one of which is the complexity and amount of data a consultant must manage in making their recommendations for care. The other 2 components are the number and severity of clinical problems, as well as the risk of morbidity and mortality. To submit a bill for the consult, the CTA is not allowed to be in direct supervision of a resident or fellow in the OR while concurrently performing a consult. This dictates that the consult be performed at a time separate from performing clinical duties in the OR or having documented relief of OR duties. Additionally, because routine preoperative exams are bundled into the billing of anesthesia services, the cardiac anesthesiology consult must go beyond a routine preoperative examination. To do this, the reason for consultation and the medical necessity of the evaluation must be documented clearly by the CTA. In creating the authors’ consultation service, the authors have developed a standardized consult note template in the authors’ EHR used by all members of the team (Fig 2). Typical
of a consult note, the note is headed by the encounter date, referring physician, consulting physician, and reason for consultation. This subsequently is followed by the history section of the note, which includes HPI; review of systems; past medical, surgical, and family history; as well as allergies, current medications, and the patient’s social history. A standardized “normal” exam of 12 organ systems follows the history section, but does allow for modification where abnormal exam findings occur or for deletion of certain organ systems if they were not included in the physical exam. In the results section, the authors have included the most recent complete blood count; basic metabolic panel; coagulation studies (ie, prothrombin time, international normalized ratio, activated partial thromboplastin time); arterial blood gas; as well as the results of the most recent electrocardiogram, echocardiography, and chest x-ray. An assessment and plan section follows the results section, allowing the CTA to confirm or decline the request, discuss why that decision has been made, and delineate any recommendations for further evaluation or perioperative testing. In addition to speaking with the requesting provider, the authors’ consult note copies the requesting physician so that
Fig 1. Electronic order of the cardiac anesthesia consult in the electronic health record.
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Fig 2. Electronic consult note showing all pertinent parts of comprehensive note.
ARTICLE IN PRESS T.E. Schulte et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2018) 1 7 Table 5 Take-Home Points About a Cardiac Anesthesia Consult Service 1. 2.
3.
Consult must be ordered by team requesting the cardiac anesthesia consultation. Consult note must contain all 3 sections of the E/M code. a. History b. Multi-System Exam c. Medical Decision-Making Determine which E/M codes you performed: 99221, 99222, or 99223.
Abbreviations: E/M, evaluation and management.
they are notified of the authors’ reply to their request for a cardiac anesthesiologist. Most of the information is prepopulated automatically into the note based on data pulled directly from the EHR. Free text writing is required in the HPI, Assessment, and Plan portions of the note. After the note is completed, it then is billed by centralized billers. The billing department ensures all required components are present and bills at the appropriate level. With a consulting physician, a phone call or communication will occur to the team stating the findings of the consultation and what additionally needs to be done. Conclusion A cardiac anesthesia consult service is becoming a vital part of the ORs at the authors’ academic medical center. By decreasing the number of OR delays, increasing the first case on time start percentage, and using OR personnel during prime-time hours, the CACS assists with OR throughput. By using appropriate tests, the CACS also is managing resources efficiently. It is important to understand the billing codes and requirements to ensure the consult service receives reimbursement for the work performed (Table 5). Communicating with medical billing and ensuring complete documentation in the electronic medical records are vital to the success of the service. References 1 Shear T, Greenberg S. Pro: CTA should provide critical care consultation in the operating room. J Cardiothorac Vasc Anesth 2014;28:1154–5. 2 Duhachek-Stapelman AL, Roberts EK, Schulte TE, et al. The cardiothoracic anesthesiologist as a perioperative consultant-echocardiography and beyond. J Cardiothorac Vasc Anesth 2018: 1–11.
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3 Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126–30. 4 Pham CT, Gibb CL, Fitridge RA, Karnon JD. Effectiveness of preoperative medical consultations by internal medicine physicians: A systemic review. BMJ Open 2017;7. 5 Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: A randomized clinical trial. Med Care 1994;32:498–507. 6 Auerbach AD, Rasic MA, Sehgal N, et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med 2007;167:2338–44. 7 Katz RI, Cimino L, Vitkun SA. Preoperative medical consultations: Impact on perioperative management and surgical outcome. Can J Anaesth 2005;52:697–702. 8 Vazirani S, Lankarani-Fard A, Liang LJ, et al. Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med 2012;7:697–701. 9 Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med 2010;170:1365–74. 10 Blitz JD, Kendale SM, Jain SK, Cuff GE, Kim JT, et al. Preoperative evaluation clinic visit is associated with decreased risk of in-hospital postoperative mortality. Anesthesiology 2016;125:280–94. 11 Wijeysundera DN, Austin PC, Beattie WS, et al. A population-based study of anesthesia consultation before major noncardiac surgery. Arch Intern Med 2009;169:595–602. 12 Ferschl MB, Tung A, Sweitzer B, et al. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005;103:855–9. 13 van Klei WA, Moons KG, Rutten CL, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644–9. 14 Shippert R. A study of time-dependent operating room fees and how to save $100,000 by using time-saving products. Am Cosmetic Surg 2005;22:25–34. 15 Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg 2018;153:1–7. 16 Anesthesia staffing models, productivity measurement, and incentive plans. In: Kaye AD, Fox CJIII, Urman RD, eds. Operating room leadership and management, Cambridge University Press 2012:151–9. 17 Schuster M, Standl T. Cost drivers in anesthesia: Manpower, technique and other factors. Curr Opin Aneasthesiol 2006;19:177–84. 18 Cross DA. Value-added services: Should expanded services always immediately contribute to the group’s bottom line? ASA Newsl 2007;71:19–20. 19 Bierstein K. Anesthesiology practice costs, revenues and production survey data. ASA Newsl 2007;71:32–3. 20 Clarification of Evaluation and Management Payment Policy. CMS Pub. 100-02, MLN Matters Number: MM7405, Transmittal: R147BP. Available at: http://www.cms.gov. Accessed August 31, 2018. 21 Evaluation and Management Services. ICN: 006764. Aug 2017 http:// www.cms.gov; Accessed August 31, 2018. 22 Questions and Answers on Reporting Physician Consultation Services. CMS Pub. 100-4, MLN Matters Number: SE1010 Revised (CR 6740, Nov 11, 2011). Available at: http://www.cms.gov. Accessed August 31, 2018.
Contents lists available at ScienceDirect
Journal of Cardiothoracic and Vascular Anesthesia journal homepage: www.jcvaonline.com
Special Article
Financial Considerations of an Anesthesia Consult Service 1
Thomas E. Schulte, MD , Amy L. Duhachek-Stapelman, MD, Austin J. Adams, MD, Tara R. Brakke, MD, Ellen K. Roberts, MD Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
Surgical patients with complex cardiac disease often require noncardiac surgery. There have been recent articles written concerning the role of the cardiothoracic anesthesiologist as a consultant in the operating room as well as outside the operating theatre.1,2 With the evolution of the cardiothoracic anesthesia consult service (CACS), there are many issues regarding medical billing, financial reimbursement, and Medicare rules that anesthesiologists may not be familiar with. This paper will discuss the financial implications of starting a CACS. Ó 2018 Elsevier Inc. All rights reserved. Key Words: cardiac anesthesia consult service; adult cardiothoracic anesthesia; perioperative evaluation; financial considerations of anesthesia billing
Background A paradigm shift has occurred in recent years regarding the preoperative assessment and optimization of surgical patients. The Perioperative Surgical Home model was developed as a method to improve clinical outcomes and decrease costs due to enhanced coordination of care in the perioperative period.3 The goal is not to minimize the benefits of pr-operative evaluation by a patient’s primary care provider or cardiologist. This physician has the most intimate knowledge of the patient’s medical history and can provide excellent insight into their level of presurgical optimization. However, there are nuances of anesthetic care that may not be recognized by the primary care physician or cardiologist. These include developing the anesthetic plan, determining the need for invasive monitoring, and assessing which steps in a surgical procedure might be associated with a high risk for patient decompensation. Postoperative concerns such as the plan for pain management, necessity for ventilation, or advanced hemodynamic support also may not be within the scope of the primary care physician’s level of expertise concerning the operative course. To address these issues in patients with significant cardiovascular Each author has written a part of the paper and agrees with the final draft. 1 Address reprint requests to Thomas E. Schulte, MD, Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE 68198-4455. E-mail address: [email protected] (T.E. Schulte). https://doi.org/10.1053/j.jvca.2018.12.007 1053-0770/Ó 2018 Elsevier Inc. All rights reserved.
disease, the authors built a successful cardiothoracic anesthesiology consult service at the authors’ institution. The authors will describe the importance of this service for patient care, as well as review the authors’ business plan for its development. Preoperative Evaluation by Nonanesthesiologists There have been mixed results regarding the benefit of preoperative assessment and optimization by nonanesthesiology specialists. To assess the benefit of preoperative consultation by internal medicine physicians, a systematic review of the literature was performed to analyze length of hospital stay, cost, morbidity, and mortality as well as quality of life in high-risk surgical patients.4 Only 4 of 128 citations screened met inclusion criteria, and they found the quality of available evidence to be poor.5 8 However, based upon the available data, the authors concluded that there was positive effect of preoperative consultation by a general internist. Conversely, a cohort study was performed using a population-based administrative database, in which 38.8% of 269,866 patients underwent consultation by internal medicine in the preoperative period. Compared to a matched cohort, patients receiving consultation had an increase in both 30-day mortality (relative risk 1.16) and 1-year mortality (relative risk 1.08), an increased mean hospital stay of 0.67 days, as well as an increase in preoperative testing and pharmacologic interventions.9 Based upon this and other work, the benefit of preoperative internal medicine consultation requires further evaluation.
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Preoperative Evaluation by Anesthesiologists In contrast to what has been published on the preoperative evaluation of patients by nonanesthesiologists, several studies have shown benefits of the anesthesiologist as a preoperative consultant.10 13 Blitz and colleagues performed a retrospective administrative database review of over 64,000 surgical patients, of which 55.2% were seen in the anesthesiologist-led preoperative evaluation clinic (PEC).10 Propensity-matched scoring resulted in 13,964 patients in each matched set, with 11 deaths in the PEC group and 23 deaths in patients not seen in the PEC. In this study, a visit to the PEC was associated with decreased mortality (odds ratio 0.48%, p = 0.04) compared to matched cohorts. Beneficial results also were found in a populationbased cohort study performed over 10 years, which analyzed 271,082 patients who underwent elective intermediate- to highrisk noncardiac surgery from 1994 to 2004.11 Thirty-nine percent of patients underwent anesthesia consultation in the preoperative period. Consultation was associated with a decrease in mean hospital length of stay (8.17 v 8.52 days, p < 0.001) in these patients; however, there was no difference in postoperative survival. Finally, studies have shown a decrease in operating room (OR) delays and cancellations when the patient is seen in the anesthesia preoperative medicine clinic.12 An additional observational study revealed a significant reduction in case cancellation, as well as a decrease in length of admission.13 The improved outcomes and decreased delays and cancellations in these patients may be owing to an understanding of the nuances of anesthetic care that are not a part of the internal medicine consultant’s area of expertise. Data regarding improvements in length of stay and mortality with preoperative consultation by an anesthesiologist provide support for assessment and optimization. It may follow that even further improvements will occur when consultation is performed by experts in the operative care of cardiac patients presenting for noncardiac surgery. Further studies will help to elucidate if the utilization of cardiac anesthesiology consultants for patients with complex cardiac diseases will lead to improved outcomes in these patients. Within the specialty of anesthesiology, there is variability in expertise in caring for certain subsets of patients. For example, not all anesthesiologists are familiar with congenital cardiac disease, advanced mechanical support devices, or the care of patients with critical valve disease or end-stage cardiac disease. It is in these patients that consultation by the cardiothoracic anesthesia consult service (CACS) has the potential to provide the most benefit. The CACS provides value in preoperative risk assessment, intraoperative hemodynamic monitoring, echocardiography skills, and postoperative direction in patients with complex cardiac disease presenting for noncardiac surgery.2 Efficiency in the OR There are several important resources in the perioperative area, some of which include time, testing/equipment, and personnel. The development of a CACS may lead to appropriate utilization of these resources through a number of mechanisms.
The first of these mechanisms is the cost of OR time when a case is delayed or canceled. The cost estimate of OR time has been found to be highly variable. Although the authors do not know the exact cost of running an OR, underutilized OR time is a significant expense. Published estimates vary quite widely, from $21/min to $133/min.14,15 The incorporation of a CACS into a clinical practice may prevent delays of surgical care for noncardiac procedures. The hospital then may realize financial benefits through a decrease in wastage of the costly resource of OR time through the development of mechanisms to minimize delays and cancellations. For example, consultation may lead to performance of an echocardiogram earlier in the patient’s care, avoiding a last-minute delay waiting for additional tests. Conversely, after evaluation by the CACS, it may be determined that the patient needs no further workup, which will allow the procedure to continue on schedule. Finally, if it is determined after CACS evaluation that the patient does not need to be cared for by a cardiothoracic anesthesiologist (CTA), an appropriate care team can be assigned to the procedure, thereby avoiding unnecessary delays. This scenario would allow the case to be done during prime-time OR hours, rather than after the CTA finished their cardiac case, decreasing OR personnel overtime. Hospitals also may see an improved optimization of the use of important resources, such as the need for an echocardiogram or referral to the patient’s cardiologist for stress testing or medical optimization. The CACS also may limit unnecessary testing and thereby decrease healthcare expenditures. The goal in these cases is to use resources when they clearly are indicated and avoid unnecessary interventions. This also will optimize the use of equipment, which is yet another valuable resource. In addition to the above mechanisms, the use of personnel resources in an appropriate staffing model can lead to financial benefit. Personnel costs make up most of the operating expenses, therefore it is important to match an efficient staffing model to needs.16,17 In a previous article, the authors discussed how to estimate needs and therefore the required personnel number for providing the service.2 With decreasing reimbursement rates and increasing demands for expanding services, most anesthesiology practices require hospital subsidization to balance their budget.17,18,19 Although hospital stipends for anesthesia services are common, the expectation remains to contain or decrease costs. One way to minimize cost of the service is to create a staffing model that does not require additional full-time-equivalent CTA providers but still allows for the institution of a CACS. Staffing a CACS When developing a staffing model, it is necessary to determine whether a CTA can cover consults while simultaneously covering an OR site. This model would allow the consults to occur without disrupting scheduled OR cases. This should be an option if the OR staffing model consists of an anesthesiologist medically directing a resident, fellow, or certified nurse anesthetist. At the authors’ institution, the CTA covers 1 site while medically directing a resident or fellow (1:1 staffing ratio). The on-call CTA covers the CACS and has the responsibility to find coverage for all
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the consults. This often means delaying the consult until one of the CTA team members is available to evaluate the patient for the CACS after their OR cardiac case. Although this may be reasonable for inpatient consults, this model is impractical for consults in the anesthesia pre-evaluation clinic. The time-sensitive nature of evaluating these patients would be better served with the staffing model discussed below. An additional option is to have one of the CTAs medically direct 2 sites (1:2 staffing ratio), while the second room’s CTA performs the consult. Ensuring that the second site is covered by a CTA who is not the primary anesthesiologist covering the consult allows reimbursement for the consult. This flexibility in staffing allows for all scheduled operations to continue, the consult to be performed and evaluated in real time, and full reimbursement of the consult performed to occur. This coverage must be reflected in the electronic health record (EHR) because anesthesiologists are not able to bill for consult services outside the OR while simultaneously performing OR duties. The authors find this method of coverage to be the most practical and appreciated by the surgeons owing to the timeliness of the consult. Also, performing the consults while on cardiopulmonary bypass allows for the most opportunistic timing of the consult to be performed, as rarely is direct supervision required while on cardiopulmonary bypass. The CACS also could use personnel during their nonclinical time, as some academic groups offer this time to faculty. With this model, the CACS would require at least 1 team member to be nonclinical each day. In the authors’ experience, this model is not well received because most faculty view this as a loss of valuable time needed to pursue academic goals. The authors acknowledge that developing a staffing model in a physician-only group is more challenging. The consult could be done only after the scheduled cases, which would be fine for future surgical cases. However, this would not allow emergency consults in the OR due to patient decompensation, or in the preoperative area when the CTA physician is working solo in the OR. The OR is the financial machine of the hospital. Examples of the overall positive financial benefits of a CACS include decreasing the number of OR delays, increasing first case on time start percentage, and using OR personnel during primetime hours. When expanding services, the anesthesiology group needs to minimize costs while simultaneously developing a safe, efficient, quality-driven service. Billing Historically, billing for consultation services relied upon submitting Current Procedural Terminology (CPT) consultation codes developed and maintained by the American Medical Association to the patient’s insurance provider, along with the necessary supporting documentation of the services provided. However, as of January 2010, the Centers for Medicare and Medicaid Services (CMS) no longer recognizes or pays for consultation services using CPT consultation codes. Instead, providers now are required to report patient evaluation and management (E/M) codes for all services submitted to CMS for reimbursement, including those previously reported as CPT consultation
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codes.20 At the time of the change, this became problematic because many third-party or commercial payers still accepted the CPT consultation codes for reimbursement. In the years since, many third-party payers also have moved away from the CPT codes, now relying on the E/M codes used by CMS. Such an alignment in coding has helped simplify billing in most instances, but a limited number of commercial payers still accept the CPT consultation codes. At the authors’ institution, all requests for reimbursement of consultation services use the currently accepted standard E/M codes. Initially established by Congress in 1995 and revised in 1997, E/M standards and guidelines provide a unified method for medical billing. Evaluation and management codes reflect where a service was provided (inpatient v outpatient), but also require the provider to identify the level of complexity of medical decision-making required in providing care to a given patient.21 Following the elimination of CPT consultation codes, consultant physicians perform and bill insurance providers for what amounts to a history and physical (H&P), although the encounter may be documented as a “consult” within the patient’s EHR. To prevent the appearance of multiple H&Ps for billing purposes, the admitting physician must attach a modifier to the initial H&P to identify themselves as the primary physician of record (CMS 1). Consultant physicians should not attach the modifier to their billing code. Under E/M coding guidelines, a H&P/consult note must contain 3 key components: a history, physical exam, and medical decisionmaking. History, the first key component of E/M documentation, is subdivided further into the chief complaint; history of present illness (HPI); review of systems; and past medical, family, and social history. Based on the level of documentation, the history section can be categorized as “problem focused,” “expanded problem focused,” “detailed,” or “comprehensive” (Table 1). The second key component of E/M documentation is the physical exam. The physical exam also can be categorized into 4 levels: “problem focused,” “expanded problem focused,” “detailed,” and “comprehensive” based on the number of organ systems examined and the degree of documentation (Table 2). A cardiovascular exam may be substituted in lieu of a general multisystem exam, but the documentation requirements are different from those identified in Table 2. Medical decision-making is the final key component for E/M documentation. Medical decision-making represents the complexity of information being managed. Similar to the H&P exam components, medical decision-making is subdivided further into 4 categories, including “straightforward,” “low complexity,” “moderate complexity,” and “high complexity.” The level of medical decision-making is dependent upon the number of diagnoses, the amount and complexity of data being reviewed, as well as the risk of complication and/or morbidity and mortality to the patient (Table 3).21 Under the new guidelines set forth in January 2010, physicians report “consultations” on inpatients using initial hospital care E/M codes 99221 to 99223. Billing for E/M codes 99221 to 99223 requires that a minimum of the key components for work and/or medical necessity must be documented and met.20 If the minimum key components for codes 99221 to 99223 cannot be met for a given encounter, providers are
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Table 1 History: The First Component of Evaluation and Management (E/M) Codes1 Type of History
HPI
ROS
PMFSH
Problem focused Focused expanded problem Detailed
Brief (1-3 elements) Brief
N/A Problem pertinent (system directly related to problem) Extended (2-9 systems)
N/A N/A
Complete
Extended (>4 elements or s tatus >3 chronic conditions) Extended
Complete (>10 organ systems)
Pertinent (at least 1 item from any of 3) Complete (>1 item for each of 3 areas)
Abbreviations: E/M, evaluation and management; HPI, history of present illness; ROS, review of systems; PMFSH, past medical, family, and social history.
Table 2 Multisystem Exam: The Second Section of E/M Codes1 Type of Exam Problem focused Expanded problem focused Detailed Comprehensive
1-5 elements in 1 or more organ systems >6 elements in 1 or more organ systems >2 elements from 6 organ systems or >12 elements from 2 or more systems All elements in at least 9 organ systems or >2 elements from 9 organ systems
Abbreviations: E/M, evaluation and management.
allowed to use the subsequent hospital care visit E/M codes 99231 or 99232.20 Billing of E/M codes 99221 to 99223 may occur based on the level of documentation or based on time (Table 4). When billing is based on the level of documentation, the level of all 3 components (history, physical exam, and medical decision-making) must be sufficient to meet the minimum requirements for that particular E/M code. For CMS, a 99221 evaluation carries a value of 1.92 relative value units (RVUs) (approximately $104), a 99222 evaluation is 2.61 RVUs (approximately $138), and 99223 is 3.86 RVUs (approximately $204). Time-based billing carries no specific requirements for documentation of a history, physical exam, or medical decisionmaking, although it is recommended strongly to include this information in the consultation note. For consultation services, time-based billing is only for time spent in face-to-face consultation with the patient, and does not include time spent on the patient’s floor reviewing medical records or in discussion with house medical staff.22 The duration of the encounter must be documented when time-based billing is used. Regardless of
the decision to bill based on medical necessity or time, appropriate documentation is paramount.21 As discussed earlier, when billing for time-based patient consultation, the anesthesiologist cannot be staffing an OR while performing the consultation. At the authors’ institution, no additional medical billers were hired, nor was any additional training needed for the medical biller. Because the authors also have a critical care anesthesiology service, the billers were familiar with the codes and requirements needed at each level. For a formal consult to occur, the requesting physician must place an order in the EHR requesting evaluation by a CTA (Fig 1). Within the authors’ EHR, the authors have created an order to consult cardiac anesthesiology. This order is titled “Inpatient Consult to Cardiac Anesthesiology.” Once the order has been placed, the requesting provider then contacts the anesthesiology clinical director or the “board runner,” informing them that a request has been made for evaluation by cardiac anesthesiology, and the request is relayed to the CTA on call. At the authors’ academic institution, often the consultation evaluation first is performed by the adult cardiothoracic anesthesiology fellow, and subsequently staffed by the attending CTA after a discussion of the patient and direct evaluation by the attending. This allows for education of the fellow not only about the cardiac disease of the patient but also medical billing. In many instances, the imaging and laboratory studies are reviewed prior to performing the physical consultation. Sometimes the clinician performing the consult is not the same clinician who will provide the anesthetic, so including the results of the studies in the consultation note not only helps inform the authors’ colleagues about the patient’s medical condition, but also prevents them from having to dig through the chart to find the desired information. Additionally, including such information in the consultation note helps support the
Table 3 Medical Decision-Making: The Third Component of E/M Codes1 Type of Decision-Making
Number of Diagnoses or Management Options
Amount and/or Complexity of Data to Be Reviewed
Risk of Complications and/or Morbidity or Mortality
Straightforward Low complexity Moderate complexity High complexity
Minimal Limited Multiple Extensive
Minimal Limited Moderate Extensive
Minimal Low Moderate High
Abbreviations: E/M, evaluation and management.
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Table 4 E/M Codes2 E/M Code
History
Physical Exam
Medical Decision-Making
Time
99221 99222 99223
Detailed or comprehensive Comprehensive Comprehensive
Detailed or comprehensive Comprehensive Comprehensive
Straightforward or low complexity Moderate complexity High complexity
30 min 50 min 70 min
Abbreviations: E/M, evaluation and management.
medical decision-making component of billing, and clinical documentation is paramount in supporting billing. Medical decision-making is determined by 3 components, one of which is the complexity and amount of data a consultant must manage in making their recommendations for care. The other 2 components are the number and severity of clinical problems, as well as the risk of morbidity and mortality. To submit a bill for the consult, the CTA is not allowed to be in direct supervision of a resident or fellow in the OR while concurrently performing a consult. This dictates that the consult be performed at a time separate from performing clinical duties in the OR or having documented relief of OR duties. Additionally, because routine preoperative exams are bundled into the billing of anesthesia services, the cardiac anesthesiology consult must go beyond a routine preoperative examination. To do this, the reason for consultation and the medical necessity of the evaluation must be documented clearly by the CTA. In creating the authors’ consultation service, the authors have developed a standardized consult note template in the authors’ EHR used by all members of the team (Fig 2). Typical
of a consult note, the note is headed by the encounter date, referring physician, consulting physician, and reason for consultation. This subsequently is followed by the history section of the note, which includes HPI; review of systems; past medical, surgical, and family history; as well as allergies, current medications, and the patient’s social history. A standardized “normal” exam of 12 organ systems follows the history section, but does allow for modification where abnormal exam findings occur or for deletion of certain organ systems if they were not included in the physical exam. In the results section, the authors have included the most recent complete blood count; basic metabolic panel; coagulation studies (ie, prothrombin time, international normalized ratio, activated partial thromboplastin time); arterial blood gas; as well as the results of the most recent electrocardiogram, echocardiography, and chest x-ray. An assessment and plan section follows the results section, allowing the CTA to confirm or decline the request, discuss why that decision has been made, and delineate any recommendations for further evaluation or perioperative testing. In addition to speaking with the requesting provider, the authors’ consult note copies the requesting physician so that
Fig 1. Electronic order of the cardiac anesthesia consult in the electronic health record.
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Fig 2. Electronic consult note showing all pertinent parts of comprehensive note.
ARTICLE IN PRESS T.E. Schulte et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2018) 1 7 Table 5 Take-Home Points About a Cardiac Anesthesia Consult Service 1. 2.
3.
Consult must be ordered by team requesting the cardiac anesthesia consultation. Consult note must contain all 3 sections of the E/M code. a. History b. Multi-System Exam c. Medical Decision-Making Determine which E/M codes you performed: 99221, 99222, or 99223.
Abbreviations: E/M, evaluation and management.
they are notified of the authors’ reply to their request for a cardiac anesthesiologist. Most of the information is prepopulated automatically into the note based on data pulled directly from the EHR. Free text writing is required in the HPI, Assessment, and Plan portions of the note. After the note is completed, it then is billed by centralized billers. The billing department ensures all required components are present and bills at the appropriate level. With a consulting physician, a phone call or communication will occur to the team stating the findings of the consultation and what additionally needs to be done. Conclusion A cardiac anesthesia consult service is becoming a vital part of the ORs at the authors’ academic medical center. By decreasing the number of OR delays, increasing the first case on time start percentage, and using OR personnel during prime-time hours, the CACS assists with OR throughput. By using appropriate tests, the CACS also is managing resources efficiently. It is important to understand the billing codes and requirements to ensure the consult service receives reimbursement for the work performed (Table 5). Communicating with medical billing and ensuring complete documentation in the electronic medical records are vital to the success of the service. References 1 Shear T, Greenberg S. Pro: CTA should provide critical care consultation in the operating room. J Cardiothorac Vasc Anesth 2014;28:1154–5. 2 Duhachek-Stapelman AL, Roberts EK, Schulte TE, et al. The cardiothoracic anesthesiologist as a perioperative consultant-echocardiography and beyond. J Cardiothorac Vasc Anesth 2018: 1–11.
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3 Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126–30. 4 Pham CT, Gibb CL, Fitridge RA, Karnon JD. Effectiveness of preoperative medical consultations by internal medicine physicians: A systemic review. BMJ Open 2017;7. 5 Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: A randomized clinical trial. Med Care 1994;32:498–507. 6 Auerbach AD, Rasic MA, Sehgal N, et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med 2007;167:2338–44. 7 Katz RI, Cimino L, Vitkun SA. Preoperative medical consultations: Impact on perioperative management and surgical outcome. Can J Anaesth 2005;52:697–702. 8 Vazirani S, Lankarani-Fard A, Liang LJ, et al. Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med 2012;7:697–701. 9 Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med 2010;170:1365–74. 10 Blitz JD, Kendale SM, Jain SK, Cuff GE, Kim JT, et al. Preoperative evaluation clinic visit is associated with decreased risk of in-hospital postoperative mortality. Anesthesiology 2016;125:280–94. 11 Wijeysundera DN, Austin PC, Beattie WS, et al. A population-based study of anesthesia consultation before major noncardiac surgery. Arch Intern Med 2009;169:595–602. 12 Ferschl MB, Tung A, Sweitzer B, et al. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005;103:855–9. 13 van Klei WA, Moons KG, Rutten CL, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644–9. 14 Shippert R. A study of time-dependent operating room fees and how to save $100,000 by using time-saving products. Am Cosmetic Surg 2005;22:25–34. 15 Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg 2018;153:1–7. 16 Anesthesia staffing models, productivity measurement, and incentive plans. In: Kaye AD, Fox CJIII, Urman RD, eds. Operating room leadership and management, Cambridge University Press 2012:151–9. 17 Schuster M, Standl T. Cost drivers in anesthesia: Manpower, technique and other factors. Curr Opin Aneasthesiol 2006;19:177–84. 18 Cross DA. Value-added services: Should expanded services always immediately contribute to the group’s bottom line? ASA Newsl 2007;71:19–20. 19 Bierstein K. Anesthesiology practice costs, revenues and production survey data. ASA Newsl 2007;71:32–3. 20 Clarification of Evaluation and Management Payment Policy. CMS Pub. 100-02, MLN Matters Number: MM7405, Transmittal: R147BP. Available at: http://www.cms.gov. Accessed August 31, 2018. 21 Evaluation and Management Services. ICN: 006764. Aug 2017 http:// www.cms.gov; Accessed August 31, 2018. 22 Questions and Answers on Reporting Physician Consultation Services. CMS Pub. 100-4, MLN Matters Number: SE1010 Revised (CR 6740, Nov 11, 2011). Available at: http://www.cms.gov. Accessed August 31, 2018.