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entitled 'Medicare: Nurse Anesthetists Billed for Few Chronic Pain 
Procedures; Implementation of CMS Payment Policy Inconsistent' which 
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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

February 2014: 

Medicare: 

Nurse Anesthetists Billed for Few Chronic Pain Procedures; 
Implementation of CMS Payment Policy Inconsistent: 

GAO-14-153: 

GAO Highlights: 

Highlights of GAO-14-153, a report to congressional requesters. 

Why GAO Did This Study: 

$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. 

What GAO Found: 

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. 

Table: Share of Selected Chronic Pain Procedures Billed in Medicare 
Fee-for-Service (FFS), by Provider Type, 2009 and 2012: 

Provider[A]: Certified registered nurse anesthetist
Share of procedures: 
2009: 0.4%; 
2012: 0.3%. 

Provider[A]: Nurse practitioner or physician assistant
Share of procedures: 
2009: 1.0%; 
2012: 2.3%. 

Provider[A]: Board certified pain physician
Share of procedures: 
2009: 40.7%; 
2012: 42.5%. 

Provider[A]: Other physician
Share of procedures: 
2009: 57.9%; 
2012: 54.8%. 

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) 
data. 

Notes: Percentages may not add to 100 due to rounding. 

[A] Provider type is based largely on the specialty indicated on the 
claim. Where services are billed “incident to,” our analysis is based 
on the billing professional's specialty. 

[End of table] 

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. 

What GAO Recommends: 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-14-153]. For more 
information, contact James Cosgrove at (202) 512-7114 or 
cosgrovej@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

CRNAs Billed for Few Selected Chronic Pain Procedures, Most of Which 
Were in Rural Areas: 

After Noridian Began Denying CRNA Claims, Changes in the Number of 
Chronic Pain Procedures Billed Varied across Three Selected States: 

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: 

Faced with Challenges, MACs Inconsistently Implemented CMS's CRNA 
Payment Policy: 

Conclusion: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Overall Trends in Billing by Selected Procedure: 

Appendix III: CRNA Share of Selected Chronic Pain Procedures, by State: 

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

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Description of Selected Chronic Pain Procedures: 

Table 2: Shares of Selected Chronic Pain Procedures and Provider 
Payments in Medicare Fee-for-Service (FFS), by Provider Type, 2009 
through 2012: 

Table 3: Certified Registered Nurse Anesthetist (CRNA) Market Share 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), 2009 through 2012: 

Table 4: Number of Procedures Billed and Average Annual Growth Rate 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), 2009 through 2012: 

Table 5: Payments and Growth Rates for Selected Chronic Pain 
Procedures in Medicare Fee-for-Service (FFS), 2009 through 2012: 

Table 6: Certified Registered Nurse Anesthetist (CRNA) Market Share 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), by State, 2009 and 2012: 

Figures: 

Figure 1: Change in the Mix of Selected Chronic Pain Procedures Billed 
by Certified Registered Nurse Anesthetists (CRNA) in Medicare Fee-for-
Service (FFS), 2009 through 2012: 

Figure 2: Number of Selected Chronic Pain Procedures Billed by All 
Providers and by Certified Registered Nurse Anesthetists (CRNA) in 
Urban and in Rural Areas in Medicare Fee-for-Service (FFS) from 2009 
through 2012: 

Figure 3: Shares of Selected Chronic Pain Procedures in Medicare Fee-
for-Service (FFS) Furnished in Rural Areas, by Provider Type, 2009 
through 2012: 

Figure 4: Number of Selected Chronic Pain Procedures Billed to 
Medicare Fee-for-Service (FFS) in Montana, South Dakota, and Wyoming, 
2009 through 2012: 

Figure 5: Number of Selected Chronic Pain Procedures Billed to 
Medicare Fee-for-Service (FFS) by Rural Providers in Montana, South 
Dakota, and Wyoming, 2009 through 2012: 

Figure 6: Medicare Fee-for-Service (FFS) Payment Policies for Selected 
Certified Registered Nurse Anesthetist (CRNA)-Provided Chronic Pain 
Procedures, by State, April 2013: 

Figure 7: Medicare Fee-for-Service (FFS) Payment Policies for Selected 
Certified Registered Nurse Anesthetist (CRNA)-Provided Chronic Pain 
Procedures in Florida, Nevada, and Pennsylvania, April 2013: 

Figure 8: Medicare Fee-for-Service (FFS) Payment Policies for 
Certified Registered Nurse Anesthetist (CRNA)-Provided Evaluation and 
Management (E/M) Services, by State, April 2013: 

Abbreviations: 

AANA: American Association of Nurse Anesthetists: 

ABMS: American Board of Medical Specialties: 

ASA: American Society of Anesthesiologists: 

ASC: ambulatory surgical center: 

ASIPP: American Society of Interventional Pain Physicians: 

CMS: Centers for Medicare & Medicaid Services: 

CPT: current procedural terminology: 

CRNA: certified registered nurse anesthetist: 

E/M: evaluation and management: 

FFS: fee-for-service: 

HHS: Department of Health and Human Services: 

IOM: Institute of Medicine: 

LCD: local coverage determination: 

MAC: Medicare Administrative Contractor: 

NCD: national coverage determination: 

Noridian: Noridian Healthcare Solutions: 

NP: nurse practitioner: 

NPPES: National Plan and Provider Enumeration System: 

PA: physician assistant: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

February 7, 2014: 

The Honorable Tom Coburn: 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable David Vitter: 
United States Senate: 

The Honorable Ed Whitfield: 
House of Representatives: 

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). 
[Footnote 1] 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.[Footnote 2] 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.[Footnote 3] 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."[Footnote 4] 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.[Footnote 5] 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 [CRNA] is legally 
authorized to perform in the state in which the services are 
furnished," including chronic pain management services, effective 
January 1, 2013.[Footnote 6] 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.[Footnote 7] Thus, CMS's rule both 
sets a Medicare standard for the services that can be reimbursed and 
recognizes local variation in states' scope of practice laws. 

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.[Footnote 8] From an AANA-provided 
list of 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. 

Table 1: Description of Selected Chronic Pain Procedures: 

Chronic pain procedures: Autonomic nerve blocks; 
Description: Injections of local anesthetic agents to temporarily 
interrupt nerves or nerve trunks in order to diagnose or treat pain in 
the autonomic nervous system, a series of nerves that control several 
involuntary body movements. 

Chronic pain procedures: Epidural injections; 
Description: Injections of steroids (anti-inflammatory agents), local 
anesthetic agents, or other medication into the epidural space of the 
spine to diagnose or treat pain radiating to the arms and legs, caused 
by the irritation of nerves in the spine. Radiological guidance is 
usually used to ensure correct needle placement. 

Chronic pain procedures: Facet neurolytic destruction; 
Description: Destruction of the paravertebral facet joint nerve by a 
neurolytic agent, such as a chemical or an electric current. 
Radiological guidance is used to ensure correct needle placement. 

Chronic pain procedures: Paravertebral facet joint injections; 
Description: Injections of steroids or local anesthetic agents into 
spinal joints to treat or diagnose back pain. Radiological guidance is 
usually used to ensure correct needle placement. 

Chronic pain procedures: Somatic nerve blocks; 
Description: Injections of local anesthetic agents to temporarily 
interrupt nerves or nerve trunks in order to diagnose or treat pain in 
the somatic nervous system, which includes the nerves that extend to 
limbs. 

Chronic pain procedures: Transforaminal epidural injections; 
Description: Specific type of epidural injection that allows the 
medication to be delivered into the foramen of the spine, which 
enables the provider to isolate the precise nerve root causing the 
pain. Radiological guidance is usually used to ensure correct needle 
placement. 

Chronic pain procedures: Trigger point injections; 
Description: Injections of steroids or local anesthetic agents given 
to treat one or multiple pain points (myofascial trigger points) in a 
band of skeletal muscle. 

Source: GAO summary of information from medical literature, federal 
reports, and other sources. 

[End of table] 

To examine provider billing for the selected procedures, we analyzed 
Medicare fee-for-service (FFS) paid claims from 2009 through 2012. In 
addition, we disaggregated the data into four provider types--pain 
medicine subspecialists (pain physicians), other physicians, CRNAs, 
and nurse practitioners (NP) or physician assistants (PA)--based 
largely on the specialty indicated on the claim. For procedures that 
were billed "incident to"--whereby, for example, a physician might 
bill for a supervised procedure furnished by a CRNA, NP, or PA--the 
actual provider of the service is not indicated on the claim.[Footnote 
9] These claims indicate the specialty of the billing professional. To 
the extent that providers furnished procedures in whole or in part 
that were billed "incident to" another professional, our analysis may 
have understated the role of those provider types. To identify 
procedures billed by pain physicians, we cross-referenced the names of 
physicians listed by the American Board of Medical Specialties (ABMS) 
as board certified in pain medicine, to a list of all Medicare 
providers, as maintained by CMS through the National Plan and Provider 
Enumeration System (NPPES).[Footnote 10] We also disaggregated the 
data by provider location, including rural and urban status. 

We took additional steps in an effort to narrow our focus to 
procedures used to treat chronic pain. CPT codes do not indicate 
whether a particular procedure is used to treat chronic or acute pain. 
To focus our review on chronic pain, we excluded claims with a 
modifier that suggests that the service was likely to be peri-
operative. We also excluded procedures performed in the hospital 
inpatient setting in our trend analysis, as they are also more likely 
to be acute in nature. 

To determine the extent to which billing for the selected procedures 
changed during the period of MAC denials, we analyzed claims from 2009 
through 2012 in those states under Noridian's jurisdiction where CRNAs 
had at least 1 percent of the chronic pain provider market in the 
period before their claims were denied. We examined trends in the 
billing of our selected chronic pain procedures by all provider types, 
both statewide and in rural areas. Appendix I contains a more complete 
description of our methodology for the Medicare claims analyses.

To identify states in which MACs allow payment for selected chronic 
pain procedures and E/M services billed by CRNAs, we interviewed 
medical directors at all nine Part A and Part B MACs to determine 
whether the MAC pays for all, a subset, or no chronic pain procedures 
and outpatient E/M services.[Footnote 11] We then confirmed this 
information by obtaining coverage policies for specific CPT codes for 
each state under a MAC's jurisdiction. To review how MACs implemented 
CMS's 2013 payment policy, we interviewed CMS officials to learn about 
the development and implementation of the new rule, as well as medical 
directors from the nine MACs to determine each MAC's approach to 
implementing this policy. 

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. 

Background: 

Types of Providers and Practice Requirements: 

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. 
[Footnote 12] 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.[Footnote 13] 

Medicare Coverage and Payment for Chronic Pain Procedures: 

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.[Footnote 14] 
Typically, these LCDs do not address which types of providers may bill 
Medicare for the services, but rather stipulate certain coverage or 
billing rules.[Footnote 15] 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.[Footnote 16] 

CRNAs Billed for Few Selected Chronic Pain Procedures, Most of Which 
Were in Rural Areas: 

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.[Footnote 
17] 

CRNAs Billed for a Consistently Small Share of Selected Procedures, 
While Pain Physicians Billed for about 40 Percent of the Procedures 
Yearly: 

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. 

Table 2: Shares of Selected Chronic Pain Procedures and Provider 
Payments in Medicare Fee-for-Service (FFS), by Provider Type, 2009 
through 2012: 

Provider[A]: Certified registered nurse anesthetist (CRNA); 
Share of procedures: 
2009: 0.4%; 
2010: 0.4%; 
2011: 0.3%; 
2012: 0.3%; 
Share of payments: 
2009: 0.2%; 
2010: 0.3%; 
2011: 0.2%; 
2012: 0.3%. 

Provider[A]: Nurse practitioner (NP) or physician assistant (PA); 
Share of procedures: 
2009: 1.0%; 
2010: 1.3%; 
2011: 1.7%; 
2012: 2.3%; 
Share of payments: 
2009: 0.7%; 
2010: 0.9%; 
2011: 1.2%; 
2012: 1.9%. 

Provider[A]: Other physician; 
Share of procedures: 
2009: 57.9%; 
2010: 56.1%; 
2011: 55.3%; 
2012: 54.8%; 
Share of payments: 
2009: 56.5%; 
2010: 55.0%; 
2011: 54.5%; 
2012: 53.9%. 

Provider[A]: Pain physician[B]; 
Share of procedures: 
2009: 40.7%; 
2010: 42.2%; 
2011: 42.7%; 
2012: 42.5%; 
Share of payments: 
2009: 42.5%; 
2010: 43.9%; 
2011: 44.1%; 
2012: 43.8%. 

Source: GAO analysis of CMS data. 

Notes: Percentages may not add to 100 due to rounding. 

[A] Provider type is based largely on the specialty indicated on the 
claim. Because services billed "incident to" indicate the specialty of 
the billing professional, our analysis is based on the billing 
specialty. To the extent that CRNAs, for example, provided services in 
whole or in part that were billed "incident to" another professional, 
these data may understate the role of CRNAs in the provision of these 
procedures. 

[B] To identify procedures billed by pain physicians, we cross-
referenced the names of physicians listed by the American Board of 
Medical Specialties (ABMS) as board certified in pain medicine to a 
list of all Medicare providers. 

[End of table] 

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. 

Table 3: Certified Registered Nurse Anesthetist (CRNA) Market Share 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), 2009 through 2012: 

Selected chronic pain procedures: Autonomic nerve blocks; 
Share billed by certified registered nurse anesthetists: 
2009: 0.05%; 
2010: 0.10%; 
2011: 0.09%; 
2012: 0.10%. 

Selected chronic pain procedures: Epidural injections; 
Share billed by certified registered nurse anesthetists: 
2009: 0.91%; 
2010: 0.93%; 
2011: 0.79%; 
2012: 0.64. 

Selected chronic pain procedures: Facet neurolytic destruction; 
Share billed by certified registered nurse anesthetists: 
2009: 0.02%; 
2010: 0.03%; 
2011: 0.02%; 
2012: 0.08%. 

Selected chronic pain procedures: Paravertebral facet joint injections; 
Share billed by certified registered nurse anesthetists: 
2009: 0.21%; 
2010: 0.15%; 
2011: 0.16%; 
2012: 0.42%. 

Selected chronic pain procedures: Somatic nerve blocks; 
Share billed by certified registered nurse anesthetists: 
2009: 0.35%; 
2010: 0.48%; 
2011: 0.39%; 
2012: 0.35%. 

Selected chronic pain procedures: Transforaminal injections; 
Share billed by certified registered nurse anesthetists: 
2009: 0.15%; 
2010: 0.18%; 
2011: 0.14%; 
2012: 0.13%. 

Selected chronic pain procedures: Trigger point injections; 
Share billed by certified registered nurse anesthetists: 
2009: 0.07%; 
2010: 0.11%; 
2011: 0.09%; 
2012: 0.11%. 

Source: GAO analysis of CMS data. 

Notes: The CRNA provider type is based on the specialty indicated on 
the claim. Because services billed “incident to” indicate the 
specialty of the billing professional, our analysis is based on the 
billing specialty. To the extent that CRNAs provided services in whole 
or in part that were billed “incident to” another professional, these 
data may understate the role of CRNAs in the provision of these 
procedures. 

[End of table] 

Over time, the mix of procedures that CRNAs billed to Medicare from 
2009 through 2012 changed somewhat. (See figure1.) 

* 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. 

Figure 1: Change in the Mix of Selected Chronic Pain Procedures Billed 
by Certified Registered Nurse Anesthetists (CRNA) in Medicare Fee-for-
Service (FFS), 2009 through 2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Year: 2009; 
Epidural injections: 65.71%; 
Paravertebral facet joint injections: 15.15%; 
Transforaminal injections: 10.24%; 
Somatic nerve blocks: 6.7%; 
Trigger point injections: 1.76%; 
Facet neurolytic destruction: 0.34%; 
Autonomic nerve blocks: 0.1%. 

Year: 2010; 
Epidural injections: 63.42%; 
Paravertebral facet joint injections: 11.65%; 
Transforaminal injections: 12.53%; 
Somatic nerve blocks: 8.89%; 
Trigger point injections: 2.6%; 
Facet neurolytic destruction: 0.72%; 
Autonomic nerve blocks: 0.19%. 

Year: 2011; 
Epidural injections: 62.23%; 
Paravertebral facet joint injections: 14.61%; 
Transforaminal injections: 11.4%; 
Somatic nerve blocks: 8.39%; 
Trigger point injections: 2.61%; 
Facet neurolytic destruction: 0.57%; 
Autonomic nerve blocks: 0.19%. 

Year: 2012; 
Epidural injections: 43.1%; 
Paravertebral facet joint injections: 34.76%; 
Transforaminal injections: 9.06%; 
Somatic nerve blocks: 8.2%; 
Trigger point injections: 2.78%; 
Facet neurolytic destruction: 1.92%; 
Autonomic nerve blocks: 0.18%. 

Source: GAO analysis of CMS data. 

Notes: The CRNA provider type is based on the specialty indicated on 
the claim. Because services billed "incident to" indicate the 
specialty of the billing professional, our analysis is based on the 
billing specialty. To the extent that CRNAs provided services in whole 
or in part that were billed "incident to" another professional, they 
are not captured in this figure. 

[End of figure] 

By state, the trend among CRNAs' billing for selected chronic pain 
procedures was largely stable over the 4-year period. (See appendix 
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. 

Of All CRNA-Billed Chronic Pain Procedures from 2009 through 2011, 
Most Were Rural; In 2012, Urban CRNAs Were Dominant: 

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 figure 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. 

Figure 2: Number of Selected Chronic Pain Procedures Billed by All 
Providers and by Certified Registered Nurse Anesthetists (CRNA) in 
Urban and in Rural Areas in Medicare Fee-for-Service (FFS) from 2009 
through 2012: 

[Refer to PDF for image: multiple line graph] 

Number of selected procedures: 

Year: 2009; 
All providers, urban: 3,500,292; 
All providers, rural: 436,539; 
Certified registered nurse anesthetist, rural: 9,313; 
Certified registered nurse anesthetist, urban: 4,707. 

Year: 2010; 
All providers, urban: 3,724,510; 
All providers, rural: 462,589; 
Certified registered nurse anesthetist, rural: 9,545; 
Certified registered nurse anesthetist, urban: 5,321. 

Year: 2011; 
All providers, urban: 3,926,202; 
All providers, rural: 478,399; 
Certified registered nurse anesthetist, rural: 7,886; 
Certified registered nurse anesthetist, urban: 5,503. 

Year: 2012; 
All providers, urban: 4,152,739; 
All providers, rural: 494,793; 
Certified registered nurse anesthetist, rural: 6,182; 
Certified registered nurse anesthetist, urban: 9,717. 

Source: GAO analysis of CMS data. 

Notes: Provider type is based largely on the specialty indicated on 
the claim. Because services billed "incident to" indicate the 
specialty of the billing professional, our analysis is based on 
billing specialty. To the extent that CRNAs provided services in whole 
or in part that were billed "incident to" another professional, these 
data may understate the role of CRNAs in the provision of these 
procedures. Additionally, these data are based on provider location, 
rather than beneficiary residence. Roughly 0.2 percent of provider 
locations were uncategorized and are not reflected above. 

[End of figure] 

In rural markets, provider shares followed the national trends. (See 
figure 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. 

Figure 3: Shares of Selected Chronic Pain Procedures in Medicare Fee-
for-Service (FFS) Furnished in Rural Areas, by Provider Type, 2009 
through 2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Year: 2009; 
Other physician: 66.6%; 
Pain physician[A]: 29.4%; 
Nurse practitioner or physician assistant: 1.8%; 
Certified registered nurse anesthetist: 2.1%. 

Year: 2010; 
Other physician: 65.2%; 
Pain physician[A]: 31.4%; 
Nurse practitioner or physician assistant: 1.4%; 
Certified registered nurse anesthetist: 2.1%. 

Year: 2011; 
Other physician: 65.2%; 
Pain physician[A]: 31%; 
Nurse practitioner or physician assistant: 2.2%; 
Certified registered nurse anesthetist: 1.6%. 

Year: 2012; 
Other physician: 64.8%; 
Pain physician[A]: 31.3%; 
Nurse practitioner or physician assistant: 2.7%; 
Certified registered nurse anesthetist: 1.2%. 

Source: GAO analysis of CMS data. 

Notes: Percentages may not add to 100 due to rounding. Provider type 
is based largely on the specialty indicated on the claim. Because 
services billed "incident to" indicate the specialty of the billing 
professional, our analysis is based on the billing specialty. To the 
extent that CRNAs, for example, provided services in whole or in part 
that were billed "incident to" another professional, these data may 
understate the role of CRNAs in the provision of these procedures. 
Additionally, these data are based on provider location, rather than 
beneficiary residence. Roughly 0.2 percent of provider locations were 
uncategorized and are not reflected above. 

[A] To identify procedures billed by pain physicians, we cross-
referenced the names of physicians listed by the American Board of 
Medical Specialties (ABMS) as board certified in pain medicine to a 
list of all Medicare providers. 

[End of figure] 

After Noridian Began Denying CRNA Claims, Changes in the Number of 
Chronic Pain Procedures Billed Varied across Three Selected States: 

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. 
[Footnote 18] 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.[Footnote 
19] In 2010, 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 figure 4.) 

Figure 4: Number of Selected Chronic Pain Procedures Billed to 
Medicare Fee-for-Service (FFS) in Montana, South Dakota, and Wyoming, 
2009 through 2012: 

[Refer to PDF for image: multiple line graph] 

Year: 2009; 
Wyoming: 4,983; 
Montana: 10,618; 
South Dakota: 12,045; 
Three-state Total: 27,646. 

Year: 2010; 
Wyoming: 5,525; 
Montana: 10,133; 
South Dakota: 12,580; 
Three-state Total: 28,238. 

Year: 2011; 
Wyoming: 4,947; 
Montana: 11,680; 
South Dakota: 12,361; 
Three-state Total: 28,988. 

Year: 2012; 
Wyoming: 5,157; 
Montana: 11,569; 
South Dakota: 11,429; 
Three-state Total: 28,155. 

Source: GAO analysis of CMS data. 

Notes: The Noridian denial policy was implemented during 2011, and was 
fully implemented in 2012. Additionally, these data are based on 
provider location, rather than beneficiary residence. 

[End of figure] 

Among rural providers in Montana, South Dakota, and Wyoming, aggregate 
billing for selected chronic pain procedures declined between 2010 and 
2012, but by state, the changes varied.[Footnote 20] (See figure 5.) 
In 2010, rural providers in those states billed for 9,247 selected 
chronic pain procedures, of which CRNAs accounted for 7.4 percent. In 
2012, rural providers in those states billed for just over 8,000 
selected procedures, a 13 percent decline from 2010. The drop in the 
aggregate number of procedures billed by rural providers in those 
states was largely the result of a decline in South Dakota; Montana 
and Wyoming showed only a slight decline in billing. 

Figure 5: Number of Selected Chronic Pain Procedures Billed to 
Medicare Fee-for-Service (FFS) by Rural Providers in Montana, South 
Dakota, and Wyoming, 2009 through 2012: 

[Refer to PDF for image: multiple line graph] 

Year: 2009; 
Wyoming rural: 1,931; 
Montana rural: 4,430; 
South Dakota rural: 2,908; 
Three-state rural Total: 9,269. 

Year: 2010; 
Wyoming rural: 2,071; 
Montana rural: 4,158; 
South Dakota rural: 3,018; 
Three-state rural Total: 9,247. 

Year: 2011; 
Wyoming rural: 1,974; 
Montana rural: 4,194; 
South Dakota rural: 2,656; 
Three-state rural Total: 8,824. 

Year: 2012; 
Wyoming rural: 2,050; 
Montana rural: 3,994; 
South Dakota rural: 1,995; 
Three-state rural Total: 8,039. 

Source: GAO analysis of CMS data. 

Notes: The Noridian denial policy was implemented during 2011, and was 
fully implemented in 2012. Additionally, these data are based on 
provider location, rather than beneficiary residence. Roughly 0.3 
percent of provider locations were uncategorized and are not reflected 
above. 

[End of figure] 

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: 

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 figure 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. 

Figure 6: Medicare Fee-for-Service (FFS) Payment Policies for Selected 
Certified Registered Nurse Anesthetist (CRNA)-Provided Chronic Pain 
Procedures, by State, April 2013: 

[Refer to PDF for image: illustrated U.S. map] 

Medicare Administrative Contractor (MAC) allowed certified registered 
nurse anesthetists (CRNA) payment for all selected chronic pain 
procedures: 
Alaska; 
Arizona; 
Idaho; 
Illinois; 
Indiana; 
Iowa; 
Kansas; 
Michigan; 
Minnesota; 
Missouri; 
Montana; 
Nebraska; 
New Hampshire; 
North Dakota; 
South Dakota; 
Utah; 
Wisconsin; 
Wyoming. 

MAC allowed CRNAs payment for certain selected chronic pain procedures: 
Alabama; 
Arkansas; 
California; 
Colorado; 
Connecticut; 
Delaware; 
District of Columbia; 
Florida; 
Georgia; 
Hawaii; 
Kentucky; 
Louisiana; 
Maine; 
Maryland; 
Massachusetts; 
Mississippi; 
Nevada; 
New Jersey; 
New Mexico; 
New York; 
North Carolina; 
Ohio; 
Oklahoma; 
Pennsylvania; 
Rhode Island; 
South Carolina; 
Tennessee; 
Texas; 
Vermont; 
Virginia; 
Washington; 
West Virginia. 

MAC denied CRNAs payment for all selected chronic pain procedures: 
Oregon. 

Sources: GAO analysis of MAC information; Map Resources (map). 

Notes: Our selected chronic pain procedures were trigger point 
injections, epidural injections, transforaminal epidural 
injections, somatic nerve blocks, autonomic nerve blocks, 
paravertebral facet joint injections, and facet neurolytic 
destruction. Generally, a single MAC maintains both the Medicare Part 
A and Medicare Part B contracts for each state; however, as of April 
2013, Minnesota, Wisconsin, and Illinois had separate MACs for 
Medicare Part A and Medicare Part B. For these states, the figure 
represents the payment policies for the MAC holding the state's 
Medicare Part B contract. As of December 2013, the following states 
have undergone a change in MAC since our data collection, which may 
affect their payment policy: California, Hawaii, Illinois, Maine, 
Massachusetts, Minnesota, Nevada, New Hampshire, Rhode Island, 
Vermont, and Wisconsin. 

[End of figure] 

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. 

Figure 7: Medicare Fee-for-Service (FFS) Payment Policies for Selected 
Certified Registered Nurse Anesthetist (CRNA)-Provided Chronic Pain 
Procedures in Florida, Nevada, and Pennsylvania, April 2013: 

[Refer to PDF for image: illustrated table] 

Florida: 

MAC allowed CRNA payment for all CPT codes: 
* Trigger point injections; 
* Transforaminal epidural injections; 
* Epidural injections; 
* Autonomic nerve blocks; 
* Somatic nerve blocks; 
* Paravertebral facet joint injections. 

MAC allowed CRNA payment for only some CPT codes: 
* None. 

MAC denied CRNA payment for all CPT codes: 
* Facet neurolytic destruction. 

Nevada: 

MAC allowed CRNA payment for all CPT codes: 
* Epidural injections. 

MAC allowed CRNA payment for only some CPT codes: 
* Transforaminal epidural injections; 
* Autonomic nerve blocks; 
* Somatic nerve blocks. 

MAC denied CRNA payment for all CPT codes: 
* Trigger point injections; 
* Paravertebral facet joint injections; 
* Facet neurolytic destruction. 

Pennsylvania: 

MAC allowed CRNA payment for all CPT codes: 
* Somatic nerve blocks. 

MAC allowed CRNA payment for only some CPT codes: 
* Epidural injections. 

MAC denied CRNA payment for all CPT codes: 
* Trigger point injections; 
* Transforaminal epidural injections; 
* Autonomic nerve blocks; 
* Paravertebral facet joint injections; 
* Facet neurolytic destruction. 

Legend: MAC= Medicare Administrative Contractor; CRNA= Certified 
Registered Nurse Anesthetist; CPT= Current Procedural Terminology. 

Sources: GAO analysis of MAC information. 

Note: CPT is a uniform coding system maintained by the American 
Medical Association used to identify and bill for medical procedures 
and services under public and private health insurance programs. A 
given procedure may have several CPT codes that, for instance, may 
indicate where on the body the procedure takes place or whether 
additional levels of a procedure were performed. 

[End of figure] 

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 figure 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. 

Figure 8: Medicare Fee-for-Service (FFS) Payment Policies for 
Certified Registered Nurse Anesthetist (CRNA)-Provided Evaluation and 
Management (E/M) Services, by State, April 2013: 

[Refer to PDF for image: illustrated U.S. map] 

Medicare Administrative Contractor (MAC) allowed certified registered 
nurse anesthetists (CRNA) payment for evaluation and management 
services: 
Alaska; 
Arizona; 
California; 
Hawaii; 
Idaho; 
Illinois; 
Indiana; 
Iowa; 
Kansas; 
Kentucky; 
Michigan; 
Minnesota; 
Missouri; 
Montana; 
Nebraska; 
Nevada; 
New Hampshire; 
North Dakota; 
South Dakota; 
Utah; 
Washington; 
Wisconsin; 
Wyoming. 

MAC denied CRNAs payment for evaluation and management services: 
Alabama; 
Arkansas; 
Colorado; 
Connecticut; 
Delaware; 
District of Columbia; 
Florida; 
Georgia; 
Louisiana; 
Maine; 
Maryland; 
Massachusetts; 
Mississippi; 
New Jersey; 
New Mexico; 
New York; 
North Carolina; 
Ohio; 
Oklahoma; 
Oregon; 
Pennsylvania; 
Rhode Island; 
South Carolina; 
Tennessee; 
Texas; 
Vermont; 
Virginia; 
West Virginia. 

Sources: GAO analysis of MAC information; Map Resources (map). 

Notes: Generally, a single MAC maintains both the Medicare Part A and 
Medicare Part B contracts for each state; however, as of April 2013, 
Minnesota, Wisconsin, and Illinois had separate MACs for Medicare Part 
A and Medicare Part B. For these states, the figure represents the 
payment policies for the MAC holding the state's Medicare Part B 
contract. As of December 2013, the following states have undergone a 
change in MAC since our data collection, which may affect their 
payment policy: California, Hawaii, Illinois, Maine, Massachusetts, 
Minnesota, Nevada, New Hampshire, Rhode Island, Vermont, and Wisconsin. 

[End of figure] 

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 allow 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. 

Faced with Challenges, MACs Inconsistently Implemented CMS's CRNA 
Payment Policy: 

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. 

Three MACs Took Steps to Implement CMS Policy, While Remaining Six Did 
Not Revisit Payment Policies for 2013: 

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. 

MACs Reported Difficulty in Interpreting State Scope of Practice Laws 
and Other Constraints: 

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.[Footnote 21] 
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. 
[Footnote 22] 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. 

Conclusion: 

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. 

Recommendations for Executive Action: 

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. 

Agency Comments and Our Evaluation: 

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. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution of it until 30 
days from its date. At that time, we will send copies to the Secretary 
of Health and Human Services. In addition, the report will be 
available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix V. 

Signed by: 

James Cosgrove Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

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. 

Selection of Procedures: 

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, 

* epidural injections, 

* facet neurolytic destruction, 

* paravertebral facet joint injections, 

* somatic nerve blocks,[Footnote 23] 

* transforaminal epidural injections,[Footnote 24] and: 

* trigger point injections. 

Analysis of Medicare Claims Data: 

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.[Footnote 25] 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.[Footnote 26] The exception to this 
is the pain 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 System (NPPES).[Footnote 27] Using a name-matching 
strategy, we were able to 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. 

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. 

Changes in Billing during the Period of Noridian Denials: 

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. 

Data Reliability and Audit Standards: 

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. 

[End of section] 

Appendix II: Overall Trends in Billing by Selected Procedure: 

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. 

Table 4: Number of Procedures Billed and Average Annual Growth Rate 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), 2009 through 2012: 

Selected chronic pain procedure: Autonomic nerve blocks; 
Procedures billed: 
2009: 27,000; 
2010: 28,000; 
2011: 29,000; 
2012: 30,000; 
Average annual growth rate: 4.30%. 

Selected chronic pain procedure: Epidural injections; 
Procedures billed: 
2009: 1,008,000; 
2010: 1,014,000; 
2011: 1,049,000; 
2012: 1,069,000; 
Average annual growth rate: 1.98%. 

Selected chronic pain procedure: Facet neurolytic destruction; 
Procedures billed: 
2009: 312,000; 
2010: 323,000; 
2011: 348,000; 
2012: 374,000; 
Average annual growth rate: 6.31%. 

Selected chronic pain procedure: Paravertebral facet joint injections; 
Procedures billed: 
2009: 1,028,000; 
2010: 1,164,000; 
2011: 1,240,000; 
2012: 1,317,000; 
Average annual growth rate: 8.61%. 

Selected chronic pain procedure: Somatic nerve blocks; 
Procedures billed: 
2009: 267,000; 
2010: 274,000; 
2011: 287,000; 
2012: 368,000; 
Average annual growth rate: 11.25%. 

Selected chronic pain procedure: Transforaminal injections; 
Procedures billed: 
2009: 950,000; 
2010: 1,028,000; 
2011: 1,069,000; 
2012: 1,073,000; 
Average annual growth rate: 4.16%. 

Selected chronic pain procedure: Trigger point injections; 
Procedures billed: 
2009: 352,000; 
2010: 362,000; 
2011: 390,000; 
2012: 421,000; 
Average annual growth rate: 6.09%. 

Selected chronic pain procedure: Total; 
Procedures billed: 
2009: 3,945,000; 
2010: 4,192,000; 
2011: 4,412,000; 
2012: 4,654,000; 
Average annual growth rate: 5.67%. 

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) 
data. 

[End of table] 

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.[Footnote 28] 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). 

Table 5: Payments and Growth Rates for Selected Chronic Pain 
Procedures in Medicare Fee-for-Service (FFS), 2009 through 2012: 

Selected chronic pain procedure: Autonomic nerve blocks; 
Procedures billed: 
2009: $6.2 million; 
2010: $6.3 million; 
2011: $7.2 million; 
2012: $7.5 million; 
Average annual growth rate: 6.30%. 

Selected chronic pain procedure: Epidural injections; 
Procedures billed: 
2009: $297.0 million; 
2010: $301.2 million; 
2011: $329.0 million; 
2012: $339.6 million; 
Average annual growth rate: 4.56%. 

Selected chronic pain procedure: Facet neurolytic destruction; 
Procedures billed: 
2009: $107.9 million; 
2010: $112.7 million; 
2011: $130.7 million; 
2012: $156.2 million; 
Average annual growth rate: 13.13%. 

Selected chronic pain procedure: Paravertebral facet joint injections; 
Procedures billed: 
2009: $227.1 million; 
2010: $207.2 million; 
2011: $238.7 million; 
2012: $261.0 million; 
Average annual growth rate: 4.74%. 

Selected chronic pain procedure: Somatic nerve blocks; 
Procedures billed: 
2009: $26.4 million; 
2010: $28.9 million; 
2011: $34.3 million; 
2012: $45.6 million; 
Average annual growth rate: 20.04%. 

Selected chronic pain procedure: Transforaminal injections; 
Procedures billed: 
2009: $243.8 million; 
2010: $268. million0; 
2011: $276.5 million; 
2012: $284.7 million; 
Average annual growth rate: 5.30%. 

Selected chronic pain procedure: Trigger point injections; 
Procedures billed: 
2009: $16.9 million; 
2010: $18.2 million; 
2011: $21. million0; 
2012: $23.6 million; 
Average annual growth rate: 11.75%. 

Selected chronic pain procedure: Total; 
2009: $925.3 million; 
2010: $942.5 million; 
2011: $1.037 billion; 
2012: $1.118 billion; 
Average annual growth rate: 6.51%. 

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) 
data. 

[End of table] 

[End of section] 

Appendix III: CRNA Share of Selected Chronic Pain Procedures, by State: 

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. 

Table 6: Certified Registered Nurse Anesthetist (CRNA) Market Share 
for Selected Chronic Pain Procedures in Medicare Fee-for-Service 
(FFS), by State, 2009 and 2012: 

State: New Hampshire; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.11%; 
2012: 5.50%; 
Percentage point change from 2009 through 2012: 4.39%. 

State: Tennessee; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.96%; 
2012: 3.48%; 
Percentage point change from 2009 through 2012: 2.52%. 

State: Mississippi; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.08%; 
2012: 0.51%; 
Percentage point change from 2009 through 2012: 0.43%. 

State: Wisconsin; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.19%; 
2012: 0.41%; 
Percentage point change from 2009 through 2012: 0.22%. 

State: Kansas; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 3.82%; 
2012: 4.03%; 
Percentage point change from 2009 through 2012: 0.21%. 

State: Illinois; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.32%; 
2012: 0.53%; 
Percentage point change from 2009 through 2012: 0.21%. 

State: Alabama; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.02%; 
2012: 0.09%; 
Percentage point change from 2009 through 2012: 0.07%. 

State: Michigan; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.18%; 
2012: 0.22%; 
Percentage point change from 2009 through 2012: 0.04%. 

State: Hawaii; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00%; 
2012: 0.03%; 
Percentage point change from 2009 through 2012: 0.03%. 

State: Nevada; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.15%; 
2012: 0.17%; 
Percentage point change from 2009 through 2012: 0.02%. 

State: Indiana; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.05%; 
2012: 0.07%; 
Percentage point change from 2009 through 2012: 0.02%. 

State: Arkansas; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.08%; 
2012: 0.09%; 
Percentage point change from 2009 through 2012: 0.01%. 

State: Georgia; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.01%; 
2012: 0.02%; 
Percentage point change from 2009 through 2012: 0.01%. 

State: Virginia; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.01%; 
Percentage point change from 2009 through 2012: 0.01%. 

State: Maine; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.01%; 
2012: 0.02%; 
Percentage point change from 2009 through 2012: 0.01%. 

State: Florida; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.01%; 
2012: 0.01%; 
Percentage point change from 2009 through 2012: 0.00. 

State: Maryland; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: South Carolina; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Ohio; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Delaware; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: District of Columbia; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Massachusetts; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: New Jersey; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: North Dakota; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Rhode Island; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Vermont; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: West Virginia; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.00; 
2012: 0.00; 
Percentage point change from 2009 through 2012: 0.00. 

State: Louisiana; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.02%; 
2012: 0.01%; 
Percentage point change from 2009 through 2012: -0.01%. 

State: Connecticut; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.01%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.01%. 

State: New York; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.02%; 
2012: 0.01%; 
Percentage point change from 2009 through 2012: -0.01%. 

State: North Carolina; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.01%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.01%. 

State: Pennsylvania; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.02%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.02%. 

State: California; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.06%; 
2012: 0.02%; 
Percentage point change from 2009 through 2012: -0.04%. 

State: Alaska; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.12%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.12%. 

State: Utah; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.15%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.15%. 

State: Texas; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.30%; 
2012: 0.15%; 
Percentage point change from 2009 through 2012: -0.15%. 

State: Oklahoma; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.42%; 
2012: 1.16%; 
Percentage point change from 2009 through 2012: -0.26%. 

State: Washington; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.78%; 
2012: 0.52%; 
Percentage point change from 2009 through 2012: -0.26%. 

State: Missouri; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.42%; 
2012: 0.11%; 
Percentage point change from 2009 through 2012: -0.31%. 

State: Kentucky; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.86%; 
2012: 0.54%; 
Percentage point change from 2009 through 2012: -0.32%. 

State: Idaho; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.07%; 
2012: 0.63%; 
Percentage point change from 2009 through 2012: -0.44%. 

State: Oregon; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.56%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.56%. 

State: Colorado; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.88%; 
2012: 0.18%; 
Percentage point change from 2009 through 2012: -0.70%. 

State: Minnesota; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 2.64%; 
2012: 1.93%; 
Percentage point change from 2009 through 2012: -0.71%. 

State: Arizona; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 0.82%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -0.82%. 

State: New Mexico; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.36%; 
2012: 0.28%; 
Percentage point change from 2009 through 2012: -1.08%. 

State: South Dakota; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.35%; 
2012: 0.00; 
Percentage point change from 2009 through 2012: -1.35%. 

State: Wyoming; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 1.61%; 
2012: 0.02%; 
Percentage point change from 2009 through 2012: -1.59%. 

State: Nebraska; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 4.23%; 
2012: 2.62%; 
Percentage point change from 2009 through 2012: -1.61%. 

State: Iowa; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 7.27%; 
2012: 4.30%; 
Percentage point change from 2009 through 2012: -2.97%. 

State: Montana; 
Percentage of procedures billed by certified registered nurse 
anesthetists: 
2009: 8.08%; 
2012: 0.26%; 
Percentage point change from 2009 through 2012: -7.82%. 

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) 
data. 

Notes: The CRNA provider type is based on the specialty indicated on 
the claim. Because claims for services billed "incident to" indicate 
the specialty of the billing professional, our analysis is based on 
the billing specialty. To the extent that CRNAs provided services in 
whole or in part that were billed "incident to" another professional, 
these data may understate the role of CRNAs in the provision of these 
procedures. Additionally, these data are based on provider location, 
rather than beneficiary residence. 

[End of table] 

[End of section] 

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

Department Of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

January 24, 2014: 

James Cosgrove: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Mr. Cosgrove, 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Medicare — Nurse Anesthetists Billed for 
Few Chronic Pain Procedures; Implementation of CMS Payment Policy 
Inconsistent" (GA0-14-153). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

The Department Of Health And Human Services' (HHS) General Comments To 
The Government Accountability Office's Draft Report, Entitled, 
"Medicare — Nurse Anesthetists Billed For Few Chronic Pain Procedures; 
Implementation Of CMS Payment Policy Inconsistent" (GAO-14-153): 

The Centers for Medicare & Medicaid Services, within HHS, issued a 
final rule, effective January 2013, clarifying that certified 
registered nurse anesthetists (CRNA) can bill Medicare for any 
services, including chronic pain management services, that a CRNA is 
legally authorized to perform in the state in which the services are 
furnished. GAO found from 2009 to 2012 that CRNAs billed Medicare fee-
for-service for a minimal share of selected pain procedures, less than 
one half of one percent of these procedures each year. Additionally, 
GAO found that three of the nine Medicare Administrative Contractors 
(MACs) took steps to implement CMS's rule. GAO concluded that MACs 
have not implemented CMS's 2012 payment rule in a consistent manner 
that ensures appropriate beneficiary coverage and provider payment. 
GAO expressed concern that 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 affected. 

The GAO recommendations and HHS responses to those recommendations are 
discussed below. 

GAO Recommendation: 

The GAO recommends that CMS 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. 

HHS Response: 

HHS concurs with the recommendation. Section 1861(bb)(1) of the Social 
Security Act defines the term "services of a certified registered 
nurse anesthetist" as "anesthesia and related care furnished by a 
certified registered nurse anesthetist...which the nurse anesthetist 
is legally authorized to perform as such by the State in which the 
services are furnished." While we recognize that state scope of 
practice laws vary in their detail and specificity, state officials 
are in the best position to determine the scope of anesthesia and 
related care that CRNAs are allowed to furnish in their state and any 
required conditions that are applied. CMS plans to send out a letter 
to all of the MACs indicating that if it is not clear whether the 
state scope of practice allows CRNAs to perform the services for which 
they are billing, they should seek clarification from the appropriate 
state officials or entities, such as the board of nursing. By 
consulting with state officials, contractors will have the best 
information about individual state laws upon which to determine local 
Medicare payment policy. 

GAO Recommendation: 

The GAO recommends that CMS clarify the applicability of the CRNA 
supervision rule to payment for CRNA-provided chronic pain management 
services. 

HHS Response: 

HHS concurs with the recommendation, and CMS will clarify that the 
supervision rule contained in the Medicare Conditions of Participation 
governs only anesthesia services furnished in hospitals or ambulatory 
surgical centers (ASCs). The supervision rule does not apply to non-
anesthesia services furnished in hospital or ASCs nor to any service 
furnished outside of those settings, such as services furnished in the 
home or in a physician's office. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] Institute of Medicine, Relieving Pain in America: A Blueprint for 
Transforming Prevention, Care, Education, and Research (Washington, 
D.C.: 2011). 

[2] E/M services are provided by physicians and nonphysicians to 
assess patients' health and manage their care. 

[3] IOM reported that certain interventional pain procedures may be 
effective for some patients, but that the usefulness of some 
interventional procedures may be "doubtful." It also identified a 
number of shortcomings in the way chronic pain is managed, including 
insufficient provider education in chronic pain and limited access to 
care in rural areas. 

[4] 42 U.S.C. § 1395x(bb)(1) (codifying section 1861(bb)(1) of the 
Social Security Act). 

[5] MACs are private contractors that assist CMS, an agency within the 
Department of Health and Human Services (HHS), in administering the 
Medicare program. They are responsible for reviewing and paying claims 
in accordance with Medicare policy, conducting provider outreach and 
education on correct billing practices, helping implement CMS-issued 
national coverage policy, and developing local coverage policies. 

[6] 77 Fed. Reg. 68892, 69005-09 (Nov. 16, 2012) (codified at 42 
C.F.R. § 410.69). 

[7] Each state has its own scope of practice laws, which typically 
define a physician or nonphysician provider's practice, 
qualifications, board representation, and fee/renewal schedule. 

[8] CPT is a uniform coding system maintained by the American Medical 
Association used to identify and bill for medical procedures and 
services under public and private health insurance programs. 

[9] Providers sometimes use modifiers to provide additional 
information on the claim about a service or procedure submitted to 
CMS. In 2009, the HHS Office of Inspector General recommended that CMS 
create a modifier that can be used to identify services billed
“incident to.” CMS disagreed, citing difficulties distinguishing 
between services personally performed and those not personally 
performed. See HHS Office of Inspector General, Prevalence and 
Qualifications of Nonphysicians Who Performed Medicare Physician
Services, OEI-09-06-00430 (Washington, D.C.: August 2009). In December 
2013, CMS amended Medicare regulations to stipulate that services and 
supplies billed “incident to” a physician’s professional services can 
only be furnished by auxiliary personnel who “meet[ ] any applicable 
requirements to provide the services, including licensure, imposed
by the State in which the services are being furnished.” See 78 Fed. 
Reg. 74230 (Dec. 10, 2013) (to be codified at 42 C.F.R. § 410.26). 

[10] Using this methodology, we were able to match 91 percent of the 
physicians listed as pain specialists by ABMS to the list of providers 
enrolled in the Medicare program. 

[11] CMS is in the process of reorganizing and consolidating its MAC 
jurisdictions. We spoke with the MACs that process claims for Medicare 
Part A--covering hospital and other inpatient stays--and Medicare Part 
B--covering hospital outpatient, physician, and other services. As of 
April 2013, there were 12 jurisdictions and 3 states under legacy 
contracts; 9 MACs held the contracts for these jurisdictions. 

[12] The American Board of Pain Medicine also offers physicians 
certification in pain medicine. However, because it is not an ABMS 
member board, physicians receiving its certificate are not considered 
board certified in pain medicine, except for in California and 
Florida. In addition, the American Board of Interventional Pain 
Physicians offers physicians who are already board certified in an 
ABMS primary specialty the opportunity to become certified in 
interventional pain management through an examination; it is also not 
an ABMS member board. 

[13] Privileging is the process whereby a health care facility grants 
health care providers permission to furnish specific services at their 
facility. 

[14] NCDs stipulate coverage rules for the items and services that are 
reasonable and necessary for the diagnosis or treatment of an illness 
or injury. In the absence of an NCD, an item or service may be covered 
at a MAC's discretion. In this case, a MAC may issue an LCD 
stipulating the coverage and coding rules that it uses to adjudicate 
claims for such items and services. Most coverage decisions consist of 
LCDs, while there are relatively few NCDs. 

[15] CMS does not generally specify which types of physicians can bill 
for which procedures. 

[16] For most physician services, the beneficiary is responsible for 
the deductible, if not already met, and a coinsurance of 20 percent of 
the physician fee schedule. Medicare pays the remaining 80 percent of 
the physician fee schedule. 

[17] For information on general billing trends by selected procedure, 
see appendix II. 

[18] The rest of the Noridian states--Alaska, Arizona, North Dakota, 
Oregon, and Utah--had very few or no CRNA claims. Washington State is 
also in Noridian's jurisdiction; however, because CRNAs in Washington 
are dually trained and certified as NPs, the denials did not apply to 
them. In addition, Idaho Part B was under another contract until 2011. 
For these reasons, we did not include Washington or Idaho in our 
analysis of Noridian states. 

[19] In contrast, from 2009 through 2012, the number of selected 
procedures billed to Medicare FFS increased continuously nationwide 
(as shown in appendix II). 

[20] In contrast, from 2009 through 2012, the number of procedures 
billed by rural providers to Medicare FFS increased continuously 
nationwide (as shown in figure 2). 

[21] In 2000, we reported that, for NPs and clinical nurse 
specialists, state laws varied in both the services these 
practitioners were allowed to provide and the settings in which they 
could provide the services. We stated that, because the Medicare 
program did not maintain information on what each state allows, 
providers may be reimbursed for services that are not within their 
allowed scope of practice. We noted that a federal advisory group 
recommended a survey of states to establish a national database of 
allowable practices, and work with national accreditation bodies to 
establish standard minimum scopes of practice. See GAO, Medicare: 
Lessons Learned from HCFA's Implementation of Changes to Benefits, 
[hyperlink, http://www.gao.gov/products/GAO/HEHS-00-31] (Washington, 
D.C.: Jan. 25, 2000). In a 2001 50-state review of state scope of 
practice laws for NPs, PAs, and clinical nurse specialists, the HHS 
Office of Inspector General found that the state scope of practice 
laws were broad and, as a result, provided little guidance that 
contractors could use to process claims. See: HHS Office of Inspector 
General, Medicare Coverage of Non-Physician Practitioner Services, OEI-
02-00-00290 (June 2001). 

[22] 42 C.F.R. 482.52. 

[23] This category excludes injections for the facial nerve and for 
digital nerves, such as treatment for Morton's Neuroma. 

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

[25] We selected this period because Medicare's current provider 
identification system was fully implemented in mid-2008, and 2012 data 
were the most recent data at the time of our analysis. 

[26] The "other physician" category includes any physician that is not 
board certified in pain medicine; these can include generalists, such 
as family practice and internal medicine, as well as specialists, such 
as anesthesiologists and sports medicine physicians. 

[27] Specifically, the names were provided by the ABMS boards that 
certify in pain medicine: the American Board of Anesthesiology, the 
American Board of Physical Medicine and Rehabilitation, and the 
American Board of Psychiatry and Neurology. 

[28] See The Boards of Trustees, 2010 Annual Report of the Boards of 
Trustees of the Federal Hospital Insurance and Federal Supplementary 
Medical Insurance Trust Funds (Washington, D.C.: August 2010); and 
2013 Annual Report of the Boards of Trustees of the Federal Hospital 
Insurance and Federal Supplementary Medical Insurance Trust Funds 
(Washington, D.C.: May 2013). 

[End of section] 

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